iBii#ii    !'ilp!'i''i5"*i^^^ 


THE  LIBRARY 

OF 

THE  UNIVERSITY 

OF  CALIFORNIA 

LOS  ANGELES 


5371 


SEMEIOLOGY  AND  DIAGNOSIS 

OF 

DISEASES  OF  CHILDREN 

TOGETHER  WITH 

A  THERAPEUTIC  INDEX 

BY 

N.  ^ILATOV 

LATK      PROFESSOR      ORDINARY      OK      PEDIATRICS      IIS'      THE      IMPERIAL 

UNIVERSITY      OF      MOSfO\V.      AND     PH  YSIOI  AN-IN-t'HI  EE 

TO      K:HL01TI>0EF*S      children's      HOSPITAL. 

TRANSLATED      I'-ROIM      THE      RtJSSIAX 
HY 

(J.     ii.     1L.VSSIN.     M.    3) 

CHICAGO 

AVITH     KXTENSIVK     .VUDITIO^TN 
BY' 

FRANK  B.  EARLE,  M.  D. 

PROFESSOR   OF   PEDIATRICS   AND  CLINICAL  PEDIATRICS,    COLLKOK    OK 
MEDICINE   OF   THE   TTNIVERSITY'    OF    ILLINOIS,   CHICAGO. 


IN    TWO    VOLUMES 

VOLUMK    I 

JlXustratcd. 


CLEVELAND  PRESS 
CHICAGO 

1904 


Copyright  1904 

BT  THE 

CLEVELAND  PRESS 

(All  Rights  Kuscrved.; 


Bioinodical 
Library 


ERRATA. 

[A  final  comparison  of  the  printed  text  reveals  the  following  errors, 
which  the  translator  begs  the  reader  to  mark  in  the  designated  places  — 
G.  B.  H.] 

Page  85.  The  third  line  of  the  note  should  read:— this  turbidity  dis- 
appears on  shakhig.     If  there  be  added  so  much  acid,  etc. 

Page  225.     (9th  line  from  the  top)  read  nipple  (instead  of  navel). 
Page  232.     (2nd  line  from  the  bottom)  read: — the  hardness  being  nut 
very  great. 

Page  281.  (17th  line  from  the  top)  read: — after  the  operation  does 
cough  upon,  etc. 

Page  284.      (I2th   line  from  the  bottom)    read: — during  inspiration. 
Page  298.     (Qth  line  from  the  top)  read: — the  exact  diagnosis  is  pos- 
sible only. 

Page  311.     (5th  line  from  the  bottom)  read: — is  always  lower. 
Page  329.     (20th  line  from  the  top)  read : — only  in  inspiration. 
Page  341.     (8th  line  from  the  bottom)   read: — appear  later. 
Page  375.     (gth  line  from  the  bottom)    read: — appearance  of  the  re- 
action. 

Page  383.  (6th  line  from  the  top)  read: — -resemblance  to  poliomye- 
litis. 

Page  392.     (7th  line  from  the  bottom)   read: — ata.\-ia  which  does  not. 
Page  420.      (6th   line   from  the  bottom)    read: — parenchymatous   neu- 
ritis. 

Page  441.  (14th  line  from  the  top)  after  the  words  "several  days'" 
add  the  following: — the  stool  remains  normal. 

Page  442.  (15th  line  from  the  top)  should  read: — a  more  pronounced 
retardation  cannot  be  expected.  In  the  period  of  deeper  somnolency,  es- 
pecially after  convulsions,  etc. 

Page  479.     (21st  line  from  the  top)  read: — there  is  much  albumen. 
Page  492.     (2nd  line  from  the  bottom)    read: — potassic  chlorate  and 
phosphorus. 

Page  515.     (loth  line  from  the  bottom)   read: — considerably  less. 
Page  532.     (17th  line  from  the  bottom)  read: — of  the  upper  lip. 
Page  562.     (13th  line  from  the  bottom)  read: — bone  (instead  of  skin). 
Page  596.     (last  line)  read: — in  the  former  case. 
Page  606.     (7th  line  from  the  top)  read: — reaches  39.6"  (103.3'  F.). 
Page  609.     (3rd  line  from  the  top)   after  the  word  "mixed"  add  the 
following: — zvith  one  cub.  centini.  of  the  second. 

Page  623.  (6th  line  from  the  bottom)  read:— a  rough  vesicular  respi- 
ratory. 

Page  647.      (i8th  line  from  the  top)    read  :— from  the  tip. 
Page   685.      (5th   line    from   the   bottom)    read :— ^rv    (instead   of   fif- 
teen). 


<9  9    9  kJkJ^^J 


Biomodical 
Library 


GREETING 

While  this  work  may  be  said  to  appeal  with  especial  force  to 
the  young-  physician,  because  of  its  unique  arrangement  along 
diagnostic  lines  and  its  exceptional  clearness  in  indicating  the 
meaning  of  particular  clinical  signs  and  groups  of  signs,  at  the 
same  time  the  practitioner  of  experience  will  find  it  a  welcome 
aid  and  medium  of  clinical  refreshment  to  his  semeiotic  knowl- 
edge. These  facts  have  been  sufficiently  vouchsafed  in  the  popu- 
larity the  treatise  has  enjoyed  in  the  original  Russian  editions, 
and  in  the  French  translation. 

It  is  believed  that  the  reader  of  this  life-work  of  a  prominent 
Russian  teacher  and  clinician  will  discover  an  attractiveness  in  ex- 
pression and  a  thoroughness  of  detail  which  are  not  very  common. 
and  therefore  are  perhaps  oftentimes  over-exalted  when  found. 
Suffice  it  to  say,  however,  that  there  is  a  style  of  statement  in 
medicine  which  gives  exceptional  interest  to  the  subject  dealt  with  ;. 
and  that  this  has  been  a  pronounced  feature  of  Filatov's  writings  is 
conceded.  Not  only  have  the  teachings  of  this  author  been  ad- 
vanced and  logical,  but  they  have  always  been  so  expressed  as  ta 
convey  the  highest  degree  of  value  and  command  the  keenest  at- 
tention and  confidence. 

The  American  editor  has  found  it  a  difficult  task  to  effect 
any  additions  to  the  translated  text;  and  deletions  none.  The 
many  editions  in  the  original  allowed  of  such  emendations  as 
seemed  proper ;  as  well  as  of  those  additions  which  would  render 
the  finally  revised  edition  wanting  in  little.  The  new  material  that 
has  been  supplied  by  the  American  editor  represents  such  more 
or  less  important  findings  or  opinions  as  have  been  brought  out 
or  suggested  during  the  past  two  years;  and  so  far  as  possible 


577959 


4  GREETIXG 

the  "line  of  thought  and  method  of  statement"  of  the  author  have 
been  approximated.  The  chief  purpose  in  this  connection  has 
been  to  preserve  the  harmony  of  the  teaching  in  every  particular. 

Many  illustrations  appear  in  this  American  edition  that  it  is 
hoped  will  at  least  not  detract  from  the  merit  of  the  text. 

So  far  as  possible  due  credit  is  given  to  the  references  from 
literature. 

A  word  should  be  said  about  the  Therapeutic  Index.  This 
is  arranged  alphabetically  and  can  be  very  readily  consulted  by 
the  reader  in  connection  with  any  particular  affection  mentioned 
in  the  text,  or  is  quickly  available  without  the  text.  This  last 
feature  is  the  best  reason  for  the  present  plan,  which  has  been 
preserved  in  the  original  under  very  favorable  general  regard. 

The  extreme  simplicity  in  all  remedial  measures  will  strike 
the  reader  at  once. 

Finally  it  may  be  mentioned  that  the  publishers  have  spared 
no  effort  of  any  kind  to  make  the  work  as  creditable  in  this  country 
as  it  has  been  in  Russia,  France  and  Germany. 


TABLE   OF    CONTENTS. 


THE  EXAMINATION  OF  CHILDREN. 

HISTORY. 

THE  OBJECTIVE   EXAMINATION    AND  THE    MKAXIXO   OF   SKI'AUATE 
SYMPTOMS  : 

The  posture  of  the  body 27 

The  expression  of  the  face  and  eyes 2S 

General  nutrition  and  complexion 29 

The  weighing-  of  children 3^ 

The  growth  of  the  body,  oi  the  bead  and  chest 32 

Atrophy  of  children S^ 

The  Examination  of  flic  Head 3^ 

Large  Head 39 

Softening  of  the  skull-bones 4^ 

Anomalies  of  the  fontanelles  and  sutures 4^ 

Tumors  of  the  head 43 

The  Exaiiiiiiafioii  of  the  Mouth,  and  Fauces 45 

The  Examination  of  the  Neck 4'^ 

The  Examination  of  the  Chest 49 

The  respiration  of  the  newdiprn S~ 

Disfigurations  of  the  chest .iS 

The  Examination  of  the  Heart 57 

The  frequenc}'  of  the  pulse   "^ 

Senieiology  of  the  Cry /- 

Cough ^  ^ 

The  Examination  of  the  Abdomen 7^ 

Senieiology  of  the  navel /  9 

The  Examination  of  the  Urine ^4 

The  Measuring  of  the  Temperature ^9 


VI  TABLE    OF    CONTEXTS 

DISEASES  OF  THE  DIGESTIVE  ORGANS. 

Diseases  of  the  Mouth  89—1 12 

a — Diseases  of  the  Mouth  zvhich  are  not  Accompanied  by 

the  formation  of  Ulcers,  nor  by  a  Fcetid  Odor: 8q 

Catarrh  of  the  mouth 89 

Changes  of  the  tongue 89 

Thrush  (Soor) 92 

Annular  desquamation  of  the  epithehum 95 

Affection  of  the  mouth  in  measles 96 

Bohn's    nodules    98 

Dentition    98 

b — Diseases  of  the  Mouth  zvhich  are  Accompanied  by  Ul- 
cerations of  the  Mucous  Membrane,  but  without  a 
Fat  id  Odor: 

Diphtheroid    stomatitis    10 r 

Aphthae  of  the  mouth   loi 

Bednar's  aphthae 103 

Ulcers  of  the  frenulum   104 

Affection  of  the  mouth  in  syphilis 104 

Bitten  wounds  of  the  tongue 104 

c — Diseases  of  the  Mouth  with  Formation  of  Ulcerations 
on  the  Mucous  Membrane,  and  Stench  from  the 
Mouth: 

Foetid  inflammation  of  the  mouth 105 

Noma  of  the  cheek   107 

Foot-and-mouth  disease   (aphthae  epizooticae) 109 

Osteogingivitis  gangrenosa  neonatorum    no 

Semeiology  of  the  Appetite 112 — 117 

Gluttony  and  loss  of  appetite 112 

Why  does  the  child  not  take  the  breast  ? 1 14 

Increased   thirst    116 

Diseases  of  the  Fauces  1 17 — 144 

I — Diseases  of  the  Fauces  Characterised  by  Red )i ess: 

Angina  catarrhalis 117 

Changes  of  the  mucous  membrane  of  the  fauces  in  in- 
fectious exanthematous  diseases   118 


TABLE    OF    CONTENTS  Vll 

2 — Diseases  of  the  Throat  with  Formation  on  the  Tonsils 
of  Whitish  Islets : 

Angina  follicularis   1 19 

Angina  lucanaris    119 

Angina  aphthosa    1 20 

Punctate  diphtheria   120 

3 — Diseases  of  the  Throat  with  Formation  of  Coats : 

Angina  herpetica   122 

Pseudo-diphtheria 122 

Diphtheria  of  the  throat 126 

Angina  scarlatinosa   134 

Angina  ulcerosa — Vincent's  Angina 135 

Angina  syphilitica    140 

Gangrenous  angina    141 

Semeiology  of  Difficult  Deglutition   144 — 147 

Spurious  and  real  dysphagia 144 

Paralysis  of  the  soft  palate 145 

(Esophagitis  corrosiva  and  thrush 145 

Stricture  of  the  oesophagus 146 

Semeiology  of  Vomiting    147 — 159 

Eructation    147 

Bloody  vomiting 148 

Common  vomiting   •. 151 

Vomiting  during  cough   152 

Gastric  and  cerebral  vomiting 152,  155 

Vomiting  from  blood-poisoning   156 

Cyclic  or  recurrent  vomiting 156 

Vomiting  from  irritable  debility  and  simulation 157 

Eructation  of  the  food  which  did  not  reach  the  stomach.  .  15S 

DISEASES  OF  THE  STOMACH  AND  BOWELS. 

Acute  Diseases  of  the  Stomach  and  Bozifels  in  Nurslings : 

Dyspepsia I59 

Fatty  diarrhoea  i6r 

Acute  catarrh  of  the  small  bowels 162 

Cholera  infantum i^4 

Acute  catarrh  of  the  large  bowels 165 

The  green  diarrhoea i^ 


Viii  TABLE    OF    CONTENTS 

Diseases  of  the  Stomach  and  Bowels  in  Elder  Children : 

Acute  and  subacute  catarrh  of  the  stomach  and  bowels.  .  167 
Periodic  diarrhoea    173 

Semeiology  of  Bloody  Stools 179 — 187 

Bloody  stools  in  constitutional  diseases   180 

Ulcers  of  the  bowels 181 

Dysentery 182 

Polypus  of  the  rectum .186 

Semeiology  of  Constipation 188 — 195 

Constipation  in  nurslings 188 

Its  causes 190 

Fissures  of  the  anus 195 

Diseases  zvhich  are  Characicrizcd  by  Obstinate  Constipa- 
tion and  Vomiting 195 — 211 

Intestinal   obstruction    195 

Pyloric   stenosis    199 

Inflammation  of  the  caecum  (appendicitis)    201 

Acute   peritonitis    209 

Gymnastic  pains  of  the  abdomen    210 

Semeiology  of  Abdominal  Pai]is 21 1 — 218 

Hypersesthesia  of  the  skin  of  the  abdomen 211 

Pain  in  the  muscles  and  aponeuroses   212 

Pain  in  the  peritoneum   212 

Pain  in  the  bowels   (catarrh,  neuralgia,  malaria) 213 

Semeiology  of  the  Distended  Abdomen   218 — 231 

A  normal  and  distended  ahdomen   2t8 

Dropsy  of  the  abdomen  (from  hydriemia,  thrombosis  of 

the  vessels,  diseases  of  the  liver)   219 

Serous  and  tuberculous  peritonitis   224—228 

Tumors  of  the  Abdomen  231 — 242 

Enlargement  of  the  liver 2^2 

Enlargement  of  the  spleen   235 

Tumors  of  the  kidneys   239 

Tumors  of  the  retroperitoneal  glands 241 

Helminthiasis    243 — 25 1 

DISEASES  OF  THE  ORGANS  OF  RESPIRATION. 

a — Diseases  of  the  Nose  252—259 

Rhinitis    252 


TABLE    OF    CONTENTS  ix 

Diphtheria  of  the  nose 2^3 

Chronic  snuffles    254 

Epistaxis    258 

b — Diseases  of  the  Larynx  and  Trachea  Characterised  bv 

Stenotic  Respiration    260 — 279 

Acute  diseases  of  the  larynx  prodncino-  its  stenosis: 

False  croup  and  true  croup 262 

Qidema  of  the  larynx   265 

Foreign  bodies  in  the  larynx  and  nuiscular  spasm 267 

Retropharyngeal  abscess 269 

Chronic  Strictures  of  the  Upper  Respiratory  Branches: 

Syphilis  of  the  larynx   273 

New  growths    274 

Perichondritis  laryngea 274 

Tumor  of  the  thyroid  gland 275 

Hyperplasia  of  the  bronchial  glands 275 

c — Diseases  of  the  Lungs  in  -wJiieli  the  Percussion  Sound 

is  Xornially  Clear 279 — 306 

Catarrh  of  the  respiratory  branches   279 

Bronchitis  crouposa   280 

Chronic  pharyngitis  and  pcri(^dic  niglU-cough 282 

Capillary  broncliitis    283 

Bronchial  asthma   284 

La  grippe    286 

Whooping-cough    298 

(Edema  of  the  lungs 305 

Emphysema   3^5 

d — Diseases  of  the  Lungs  zvhich  are  Characterized  by  a 

Dull  Percussion  Sound  306 — 336 

Croupous  pneumonia   3^^ 

The  diagnosis  of  pneumonia  from  pleuritis 310 

Abnormal  forms  of  pneumonia: 

Abortive   pneumonia    3^5 

Cerebral  pneumonia 3^4 

Convulsive  pneumonia    3^4 

Aleningeal  pneumonia   3^^ 

Wandering  pneumonia    3^7 

Catarrhal    pneumonia    3^'^ 

Hypostatic  pneumonia 3^1 


TABLE    OF    CONTEXTS 

Pneumonia  during  la  grippe   324 

Pleuritis  329 

Hydrothorax   335 

Pneumothorax    335 

e — Diseases  of  the  Lungs  with  Foetid  Secretion 336 — 339 

DISEASES  OF  THE  NERVOUS  SYSTEM. 

Semeiology  of  Headache 339 — 348 

Acute  headache    339 

Headache  during  diseases  of  the  brain 340 

Chronic  headache 342 

Migraine    343 

Supraorbital   neuralgia    344 

Headache  from  malnutrition 344 

School  headache 345 

Headache  from  anom'aly  of  refraction  346 

Semeiology  of  General  Convulsions 348 — 371 

Cerebral  convulsions   349 

Febrile  convulsions    350 

Afebrile  convulsions  in  older  children   355 

Afebrile  convulsions  in  children  under  the  age  of  two- 
and-a-half  years 359 

St.  Vitus'  dance 362 

Tic  convulsif  and  spasmus  nutans 366 

Tetania 367 

Contraction  of  the  Muscles  of  the  Neck 371 — 374 

Contraction  of  the  neck 371 

Lateral  contraction  of  the  neck 7)7^ 

Semeiology  of  the  Paralyses 374 — 420 

The  difference  between  central  and  peripheral  paralyses. 374 

Paralyses  imth  Flaccidity  of  the  Muscles : 

Infantile  paralysis    376 

Striimpel's  cerebral  paralysis 380 

Polyneuritis 383 

Inflammation  of  the  spinal  cord  384 

Progressive  muscular  atrophy 385 

The  weakness  of  the  legs  in  rachitis  387 

False  paralysis   (epiphyseal  syphilis)    38S 

Post-natal  paralyses 389 


TABLE    OF    CONTFtNTS  XI 

Diphtheritic   paralysis    390 

Paralytic  chorea  392 

Hysterical  paralysis  394 

Facial  paralysis    397 

Bilateral  cerebral  infantile  paral\sis 398 

Unilateral  cerebral  paralysis    402 

Idiopathic  spastic  paralyses 404,  407 

Pott's  disease   4^0 

Spondylitis  of  the  neck 415 

Ataxia    420—433 

Inflammation  of  the  Cerebral  iMcmbraitcs 433 — 473 

Pathologico-anatomical  characteristics   433 

Etiology    434 

Tubercular    niening-itis    437 

Acute  simple  hydrocephalus  . 452 

Meningitis   circumscripta    453 

Hydrocephaloid 453 

Passive  hyperaemia  of  the  brain 455 

Thrombosis  of  the  sinuses ; 45''> 

Suppurative  inflammation  of  the  pia  mater 457 

Epidemic  cerebro-spinal  meningitis    462 

False  meningitis 468 

DISEASES   OF  THE   GENITO-URINARY   ORGANS. 

.Semeiology  of  the  Urine   473 — 5^^ 

Albuminuria 473 

Acute  parenchymatous  nephritis   477 

Acute  interstitial  nephritis 481 

Qironic  parenchymatous  nephritis   4^3 

Amyloid  of  the  kidney   4^4 

Hypostatic  kidney  (passive  hypenemia  of  the  kidney) .  .  .485 

Primary  interstitial  nephritis   4^6 

Haematuria 4^6 

-  Haemoglobinuria  49- 

Pyuria    493 

''Semeiology  of  Micturition  500 — S'^7 

Hindered  and  painful  micturition   ^00 

Incontinentia  urins   50/ 


Xll  TABLE    OF    CONTENTS 

Tumors  of  the  Scrotum  and  of  the  hv^iiiiial  Canal .  . .  .508 — 511 

Hernia    508 

Hydrocele  tunicae  vaginalis  and  of  the  spermatic  cord.  .  .508 

SEMEIOLOGY  OF  THE  SKIN  AND  OF  THE  SUBCUTA- 
NEOUS TISSUE. 

GENERAL  TINT  OF  THE  SKIN. 

a — Diseases  Characterised  by  Paleness  of  the  Skin  : 

Common  anaemia    512 

Infantile  splenic  anaemia 518 

Anaemia  pseudo-leukaemica  of  Jaksh 519- 

Leukaemia 520 

Malignant  anannia   522 

CTilorosis    524 

b — Diseases  Characterised  by  Yellozc  lint  of  the  Skin  : 

Icterus  of  the  new-born   5.25 

Cyanosis   afebrilis   icterica   perniciosa   cum   haemoglobi- 

nuria   ( Winkel's  disease )    525 

Icterus  catarrhalis    526 

Infectious   jaundice    526- 

c — Diseases  Characterised  by  Bluish  Ti)it  of  the  Skin  : 

Cyanosis 528 

Exanthematous  Diseases    529 — 564 

d — Diseases  Characterised  Chiefly  by  Redness  of  the  Skin  : 

The  physiological  erythema  of  new-born   529 

Dermatitis  exfoliativa    529- 

Erysipelas    531 

Erythema   caloricum    5  32 

Erythematous  prodromal  small-i)ox  rash   532 

Spotted  erythemata    533 

Roseola 533 

Erythema  multiforme    535 

Erythema  nodosum    536- 

Spotted  form  of  herpes  tonsurans    537 

Medicamentous  eruptions   '. 538. 

e — Diseases  Characterised  by  Small  Hcrmorrhages  in  the  Skin  : 

Traumatic  petechiae   539 

Purpura   simplex,   haemorrhagica   and   rheumatica 540- 

Barlow's   disease    542: 


TABLE    OF    CONTENTS  XUl 

Purpura  urticans    544 

Purpura   f ulminans    544 

Purpura  variolosa    545 

/ — Diseases  of   the  Skin    Characterised   by  Fonnatioit   of 
I'csiculd,  Abscesses  and  Crusts: 

Varicella 547 

Sudaniina 547 

Herpes  and  herpes  zoster 5^8 

Eczema 5-19 

Seborrhoea 549 

Favus 550 

Herpes  tonsurans   552 

Impetigo  simplex  and  contagiosa  . . 553 

Ectyma 554 

^ — Diseases  of  the  Skin  Characterized  by  Formation   of 
Separately  Located  Blebs: 

Pemphigus 554 

h — Diseases  of  the  Skin  Characterised  by  pruritus  ( ilehini:_ )  : 

A  common  itching  of  the  skin 554 

Papular  eczema,  prurigo,  scabies   555 

/ — Skin-Diseases  ivith  Induration  or  CEdenia  of  the  Sub- 
cutaneous Tissue : 

Sclerema  neonatorum    558 

(Edema  of  the  body  and  of  se])arate  parts  of  the  body .  .  .  559 

Neuropathic   oedema    563 

Subcutaneous   emphysema    565 

INIyxoedema    5^5 

CONSTITL^TIONAL     CHRONIC    AFEBRILE   DISEASES 
WITH    VARIOUS    LOCALIZATIONS. 

a — Scrofulosis 5^7 — 57<^ 

Its  symptoms    S^S 

Diflferential  diagnosis  between  leukaemia  and  hereditary 
late    syphilis    5^9 

b— Rachitis   57i— 57^ 

Symptoms  of  a  developed  and  a  beginning  rachitis 572 

The  difiference  from  syphilis   57^^ 

c — Hereditary  Syphilis   S77 — 593 

Its   symptoms    S77 


Xiv  TABLE    OF    CONTENTS 

Syphilis  hereditaria  tarda   57^- 

Parasyphilitic  appearances   579 

The  diagnosis  of  an  hereditary  syphihs  from  an  acquired 

one    59'^ 

FEBRILE  DISEASES. 

Febrile  diseases  of  the  skin 595 

Inflammation  of  the  glands  of  the  neck 596 

Periparotitis  epidemica   597 

Glandular  fever   59^ 

Otitis 599 

Snuffles 599 

Diseases  of  the  mouth  and  throat    599 

Diseases  of  the  lungs,  heart  and  bones 600 

Local  diseases  with  a  latent  course 601 

FEBRILE    DISEASES    WITHOUT    STRICT    LOCALIZA- 
TIONS. 

DISEASES  ClIAR.\CTEKlZi:i)  I'.V  FEVER  OF  THE  CONSTANT  TYPE. 

a — Typhoid  Fever   603 — 618 

Reaction  of  Gruber  and  Widal 603 

Symptoms    605 

Typhus  levis  and  gravis   6to 

The  diagnosis  of  typhoid  fever  from  intennittens 611 

From  typhus  fever    612 

From  tuberculosis    613 

From  typhoid  form  of  tubercular  meningitis 615 

From  ulcerous  endocarditis  and  suppurative  meningitis.  .615 
From  osteomyelitis    6t6 

b — Relapsing  Fever 618 

c — Acute  Miliary  Tuberculosis 620 — 629 

Its  dififerent  forms   621 

Typhoid  form  of  tuberculosis 621 

Subacute  form   624 

The  diagnosis  from  typhoid  fever 625 

Chronic  influenza 626 

d — Diseases  with  Intermittent  Fever 630 — 643 

Malaria 63a 

Its  atypical  forms    630 — 641 


TABLE    OF    CONTENTS  XV 

Anaemic  fever   5^  c 

Hysterical  fever    638. 

FEBRILE  DISEASES  OF  TYPICAL  COURSE  WITH  LO- 
CALIZATION OX  THE  SKIN. 

a — Exantheniatous  Fevers   644 — 645 

b — Scarlatina 645 — 658 

Symptoms    646 

Its  different  forms  651 

The  diagnosis  from  measles 653 

From  scarlatinous  rubeola 654 

From  sudamina    656 

From  medicamentous  rash   656 

From  variolous  erythema   657 

c — Measles 658 — 666 

Symptoms    658 

Different   forms    661 

Diagnosis  in  the  prodromal  period  and  in  the  period  of 

eruption    663. 

The  diagnosis  from  rubella 665 

d — Small-pox    666 — 669 

c — Varicella 669 

APPENDIX  671 

THERAPEUTIC  IXDEX   .675—806 

TABULATIONS    809—814 

PRESCRIPTION   IXDEX    815— 82r> 

GEXERAL  INDEX 


EXAMINATION    OF   CHILDREN 

The  examination  of  elder  children  does  not  exhihit  anv  great 
peculiarities  in  comparison  with  that  of  adults,  so  that  we  shall 
here  take  into  consideration  especially  small  children,  those  about 
two  years  old. 

Proceeding-  to  the  inspection  of  such  a  child  the  phvsician 
must  first  of  all  take  care  not  to  frighten  his  patient,  as  his  violent 
cry  and  restlessness  may  hinder  the  examination.  It  is  best,  enter- 
ing the  patient's  room,  not  to  pay  any  attention  for  a  while  to  him, 
but  to  occupy  one's  self  with  the  history  of  the  disease  and  thus 
let  tlie  child  contemplate  the  new  person ;  the  examination  will 
then  be  more  successful.  It  is  needless  to  say  that  one  must  not 
only  with  caution  begin  procedures  which  are  disagreeable  for  the 
child,  but  also  those  that  are  painful.  For  this  reason  it  is  better, 
for  instance,  to  perform  percussion  and  auscultation  after  the 
general  inspection  of  the  bo<ly,  counting  of  the  respiration,  etc. ; 
and  the  examination  of  the  throat  and  mouth  should  l)e  the  last 
act,  because  no  reconciliation  with  the  physician  can  take  place 
after  this. 

Anamnesis  (History  of  the  Disease).  The  examination 
thus  begins  with  the  anamnesis,  but  one  should  first  of  all  let  the 
mother  describe  whatever  she  pleases,  otherwise  she  will  constant- 
ly interrupt  the  further  questions,  turning  them  aside  perhaps. 

There  should  be  asked  : — What  is  the  matter  with  the  child  ? 
How  long  since  the  sickness  began?  What  was  noticed  first  of 
all ;  and  wdiat  came  afterwards  ?  The  next  query  should  be  about 
the  child's  age,  as  the  decision  of  this  question  determines  the 
further  examination  and  the  physician's  considerations,  not  only 
regarding  the  diagnosis  of  the  given  case,  but  also  the  prognosis 
and  treatment. 

The  influence  of  age  upon  diagnosis  is  apparent,  first,  by 
some  diseases  occurring  especially  often  or  exclusively  during 
a  certain  age,  as  those  which  are  described  in  some  text-bcxiks 


l8  KXAMINATJON    OF    CHILDREN 

as  diseases  of  the  new-born,  among  which  are  inohuled  asphyxia, 
tetanns,  cephalh?ematoma,  blenorrhoea  of  the  eyes,  etc. 

In  the  first  months  of  hfe  stomach  diseases  are  frequent, 
especially  colics  and  dyspepsia;  during  the  first  three  months 
inherited  syphilis  makes  itself  evident,  and  somewhat  later  rachitis 
of  the  head.  During  the  period  of  dentition,  i.  e.,  from  the 
seventh  up  to  the  thirtieth  month,  and  during  the  weaning  of  the 
child,  there  is  an  especial  tendency  to  catarrh  of  the  bowels, 
diseases  of  the  mouth,  rachitis,  spasm  of  the  larynx,  and  eclamp- 
sia; after  three  years,  to  different  infectious  diseases,  catarrh  of 
the  respiratory  organs  and  tuberculosis. 

Second,  the  age  may  still  influence  the  diagnosis,  because 
the  semeiotic  meaning  of  the  symptoms  may  become  decidedly 
changed  with  age.  Let  us  take  jaundice,  for  an  example ;  while 
in  the  new-born  the  pliysician  does  not  give  any  attention  to  it, 
looking  upon  it  as  a  physiological  occurrence,  in  elder  children 
this  symptom  alwa\s  has  a  pathological  meaning.  Let  us  take 
another  example :  The  child  often  suffers  from  general  convul- 
sions, being,  during  the  intervals,  entirely  free  from  any  cerebral 
symptoms.  The  question  then  arises  as  to  the  character  of  such 
symptoms.  Lf  the  child  be  in  the  age  of  dentition  then  rachitis 
or  laryngo-spasm  are  probable ;  if,  however,  he  be  about  six  years 
old,  then  epilepsy  is  more  likely.  I  could  give  very  many  similar 
illustrations,  as  like  deductions  refer  to  the  majority  of  symptoms, 
so  great  is  the  separate  importance  of  age  in  the  question  of 
diagnosis. 

Of  next  consequence  are  questions  regarding  the  liygiciiic- 
dictclic  enz'irojujiciit  of  the  baby,  i.  e.,  his  dwelling  and  feeding. 
This  information  is  necessary,  first,  for  the  establishment  of  the 
correct  diet  of  the  patient,  and  second,  it  clears  away  the  setiology 
of  the  most  common  children's  diseases,  as  intestinal  catarrhs  and 
malnutrition  in  the  form  of  rachitis,  scrofulosis,  anaemia,  obesity 
and  marasmus. 

First  of  all  one' inquires  if  the  child  has  been  fed  naturally 
by  breast-milk,  or  artificially  by  the  bottle? 

If  the  child  has  been  nourished  by  breast-milk,  then  whether 
the  mother  herself  suckles,  or  is  a  wet-nurse  employed?  (Before 
the  third  month  a  child  should  be  given  the  breast  every  two  hours 
during  tile  day,  and  every  three  hours  during  the  night,  i.  e.,  ten 


EXAMINATION    OF    CHILDREN  IQ 

times  in  twenty-four  hours  ;  after  the  third  month,  cverv  three 
hours  during-  the  day  and  twice  in  the  niglit,  total  seven  times 
during  twenty-four  hours). 

How  long  (how  many  minutes)  is  the  child  allowed  each 
time  to  take  the  hreasts,  and  are  these  drawn  alternately?  (The 
quantity  of  milk  heing  sufficient,  the  child  should  not  suck  more 
than  fifteen  minutes).  It  is  very  important  to  draw  the  breasts 
alternately,  because  the  composition  of  milk  decidedly  changes 
according  to  the  amount  of  rest  to  the  breasts ;  the  milk  of  the 
just-sucked-breast  remains  dense,  rich  with  fat,  while  that  from 
one  having  rested  looks  waterish  and  blue,  so  that  if  the  child 
takes  the  breasts  by  turns,  he  will  first  suck  out  the  waterish  milk, 
then  the  dense ;  if,  however,  he  be  fed,  with  short  intervals,  from 
the  same  breast,  then  the  milk  of  the  second  sucking  w^ill  be  very 
dense. 

What  sort  of  food  has  the  mother?  (Dyspepsia  may  be 
caused  by  very  poor  meals  (fish-meals)  as  well  as  by  exclusive 
meat-meals,  and  by  everything  disturbing  the  digestion  in  the 
nursing  woman  or  doing  harm  to  her  milk,  as,  for  instance,  sour 
fruits,  some  laxative  remedies,  opium,  etc.). 

In  what  condition  is  the  health  of  the  nursing  woman,  and 
is  she  menstruating?  (Sometimes  dyspepsia  and  colics  appear 
in  the  child  onl}-  during  menstruation). 

Is  there  enough  milk  in  the  breasts?  (If  there  is  too  little 
milk,  then  the  quality  is  also  bad,  so  that  the  child  grows  thin, 
being  restless,  not  so  much  because  of  chronic  starvation,  as  from 
dyspepsia). 

If  a  wet-nurse  feeds  the  baby,  then,  beside  the  preceding- 
questions,  one  should  inquire  as  to  the  time  of  her  last  confine- 
ment? (A  considerable  difl'erence  between  the  age  of  her  own 
child  and  that  of  the  nursling  may  be  a  sufficient  cause  of  a  per- 
sistent dyspepsia,  with  its  consequences). 

Is  her  child  living,  or,  if  dead,  then  wiiat  was  the  cause 
thereof?  (The  good  health  of  the  child  while  he  was  at  the  breast 
proves  the  good  health  of  the  wet-nurse). 

Has  the  patient  had  only  one  wet-nurse,  or  several?  (In 
the  last  case  the  child  usually  suffers  from  rachitis). 

If  the  child  has  been  fed  from  the  bottle,  or  by  additional 
nutriment,  then  with  what — pure  or  diluted  milk?    and  if  diluted. 


20  EXAMINATION    OF    CHILDREN 

then  how  is  this  done?  (Pure  milk  may  be  given  to  the  baby 
after  the  first  half-year.  During  the  first  month  the  milk  should 
be  diluted  with  three  parts  of  water ;  during  the  second  and 
third  months  with  two;  later  on  i  :i  or  2:1  are  to  be  taken). 

What  has  been  added  to  the  milk  ? — water,  oat-meal,  white 
bread  or  anv  broth?  (Any  additions  of  starch  are  to  be  strongly 
prohibited  for  children  four  or  five  months  of  age,  l^ecause  such 
food  produces  stomach  diseases  as  well  as  rachitis). 

How  much  has  been  given  at  once,  and  how^  often  has  the 
feeding  been  allowed?  (Bottle-fed  children  fall  ill  most  often  be- 
cause of  over-feeding,  as  the  sense  of  satiation  is,  in  small  children, 
very  imperfectly  developed,  so  that  the  bottle  should  not  be  given 
until  the  child  stops  sucking ;  the  intervals  should  here  be  the 
same  as  in  breast-feeding  (see  above),  and  the  quantity  at  each 
feeding  should  not  exceed  fifty  grams  (about  two  ounces)  for 
each  month  of  life;  for  instance,  a  child  two  months  old  should 
be  given  one  hundred  grams  (three  ounces  and  a  half)  :  a  five 
months  old  child  two  hundred  and  fifty  grams  (eight  ounces), 
such  projx^rtions  being  practical  until  the  end  of  the  year). 

Has  anything  else  as  food  been  given?  soup,  gruel,  or  the 
nursing-bottle  used?  (The  nursing-bottle  ma\  be,  in  small 
children,  the  cause  of  thrush,  and,  after  six  months,  of  the  rotten- 
ness of  the  teeth). 

When  did  they  begin  the  additional  nutriment?  In  case  of 
sufficient  quantity  of  milk  in  the  wet-nurse,  additional  nutriment 
is  unnecessary  until  the  seventh  or  eighth  month  of  life.  If  the 
mother's  milk  be  insufficient  and  she  does  not  want  to  take  a  wet- 
nurse,  then  one  must  use  additional  nutriment  from  the  first 
months  of  life,  as  soon  the  fault  of  the  milk  becomes  clear.  From 
the  theoretical  point  of  view  it  is,  of  course,  better  to  use  breast- 
milk  as  additional  food,  i.  e.,  to  take  a  wet-nurse  in  assistance 
to  the  mother;  but  such  a  measure  is  not  very  practical,  because 
a  wet-nurse  even  rich  with  milk  will  very  soon  lose  her  supplv. 
because  of  the  insufficient  nursing,  so  that  it  is  better  either  to 
give  the  child  up  entirely  to  a  wet-nurse,  provided  a  good  one 
may  be  immediately  secured,  or  to  adopt  mixed  feeding — from 
the  bottle.  The  earlier  additional  feeding  is  begun,  the  quicker 
there  arise  disturbances  of  digestion  and  those  of  general  nutri- 
tion  (obesity,  anreniia,  rachitis). 


EXAMINATION    OF    (11 1  LDKEN  21 

Inquiring-  about  tlie  child's  room  there  are  to  be  taken  into 
consideration  the  (|uantity  of  air  in  the  room,  the  clearness  of  the 
air,  its  temperature  ( sixty-three  degrees  to  sixty-eight  degrees 
F.)  and  the  moisture  (in  a  damp  dwelling  it  is  almost  impossible 
to  bring  up  a  child  free  from  scrofulosis  or  rachitis ;  and  not  less 
noxious  is  lack  of  light).  For  the  purpose  of  determining  the 
hygienic  environment  questions  about  the  child's  bed  are  perti- 
nent (bed-curtains  not  very  permeable  for  the  air,  mattresses 
foetid  from  urine,  or  soft,  down-pillows,  used  in  disposition  of  the 
head,  soiled  by  sweat)  ;  about  the  child's  dressing  (extreme 
muffling  up  is  good  only  for  abortive  children,  however,  stiff 
swaddling  for  nobody)  ;  about  the  baths  (cool  baths  predispose  to 
cold,  hot  ones  weaken  and  may  cause  various  dermatites,  for  in- 
stance, pemphigus  of  newly-born,  also  convulsions  in  the  form  of 
tetanus).  During  the  first  six  months  bathing  is  done  usually 
once  a  day,  later,  before  the  end  of  the  year,  every  second  day 
or  twice  a  week.  The  temperature  of  the  water  should  be  for 
the  new-born  95  degrees  F.  (35  degrees  C),  later  on  93  degrees 
F.  (34  degrees  C. ),  toward  the  end  of  the  year  and  during  the 
summer  88  degrees  F.  (31  degrees  C. ). 

Having-  gone  through  with  the  hygienic  and  dietetic  en- 
vironment of  the  child,  the  physician  proceeds  to  the  previous 
health.  Was  the  child  born  at  full  term  ?  Was  the  labor  with- 
out accident  and  did  the  child  immediately  begin  to  cry? 

Abortive  children  often  remain  feeble  and  pale  for  a  long 
time,  even  for  years,  and  usually  become  rachitic,  so  that  the 
setiology  may  often  be  made  out  in  a  case  of  insufficient  develop- 
ment or  sickness  of  the  child.  IJesides  this,  if  there  was  no 
visible  cause  for  premature  labor  (disease  of  the  mother,  a  fall, 
etc.),  then  syphilis  has  to  be  suspected,  and  this  disease  is  still 
more  probable  if  one  can  ascertain  that  abortion  has  taken  ])lace 
several  times  under  the  same  parents. 

Difficult  delivery,  asphyxia  of  the  new-born,  breech  presenta- 
tion and  other  causes  of  delayed  labor  may  play  an  important  role 
in  the  aetiology  of  some  nervous  diseases,  as  spastic  hemiplegia, 
Little's  disease,  idiotism,  epilepsy. 

What  diseases  has  the  child  had? — and  has  he  suffered  from 
any  habitual  sickness,  as,  for  instance,  a  dis[)Osition  to  diarrhcca 
or  constipation,  to  cough,  or  to  eruptions?    When  did  the  erui)tit)n 


22  EXAMINATION    OF    CHILDREN 

of  the  first  teeth  take  place? — and  how  great  were  the  intervals 
between  the  groups  of  teeth  ?  (Dentition  depends  very  much  upon 
the  condition  of  the  general  nutrition,  so  that  the  normal  and 
timely  eruption  of  the  teeth  proves,  to  some  extent,  the  normal 
development  of  the  child). 

Was  the  dentition  accom]:)anied  by  any  morbid  attacks? — if 
so,  of  what  kind  ? 

Did  the  same  symptoms  appear  during  the  crujMion  of  every 
new  tooth?  (If  yes,  then  it  is  most  probable  that  Ihey  depended 
upon   the  dentition). 

It  often  occurs  that  the  mother  gives  a  negative  answer 
when  asked  if  the  child  had  ha<l  any  disease  previously ;  but  one 
has  but  to  ask  if  the  dentition  was  painful,  then  it  will  be  found 
that  the  child  manifested  dilTt'erent  symptoms.  This  singularity 
may  be  exi)lained  by  the  fact  of  the  mother  being  very  prone  to 
ascribe  all  kinds  of  sickness  of  her  baby  to  nothing  else  but  the 
teeth,  so  that  for  the  sake  of  better  clearing  up  the  history  it  is 
useful  to  put  (|uestions  regarding  previous  diseases  in  connection 
with  the  child's  "teething,"  even  in  a  case  where  the  child  is  sev- 
eral years  of  age. 

Normally,  a  seven  month's  old  child  nmst  have  two  teeth, 
toward  the  end  of  the  year — eight :  at  the  end  of  the  second  year 
— sixteen. 

When  did  the  child  ])egin  to  hold  his  head  erect?  (normally 
in  the  third  or  f(»urth  month)  ;  to  sit?  (the  ninth  to  twelfth 
month);  and  to  walk?  (between  the  twelfth  and  eighteenth 
months). 

Did  he  cease  to  walk  after  having  learned  ?  If  yes,  then  was 
it  because  of  an  acute  or  chronic  disease?  (If  the  mother  cannot 
prove  the  cause,  then  rachitis  is  more  than  probable). 

The  queries  regarding  how  many  brothers  and  sisters  had  the 
patient? — how  many  living  and  of  what  age? — and  how  many 
dead,  with  cause  of,  and  age  at,  death? — are  important  espe- 
cially to  establish  whether  there  is  in  the  family  any  hereditary 
predisposition  to  some  diseases.  It  is  well  known,  for  instance, 
that  many  children  die  in  some  families,  at  a  certain  age,  from 
tuberculous  meningitis,  even  in  the  absence  of  tuberculosis  in  the 


EXAAJINATIOX    OF    CHILDREN' 


23 


history  of  the  parents.  It  is  also  well  known  that  frequent  labors 
debilitate  not  only  the  mother,  but  also  the  offspring. 

It  is  equally  important  to  know  if  the  only  deaths  of  children 
were  those  fed  by  the  mother  herself,  or  vice  versa,  only  those 
that  were  not  fed  by  her.  The  decision  of  this  question  mav  in- 
fluence the  physician  in  advising  the  mother  as  to  the  further 
feeding  of  a  child  or  giving  it  up  to  a  wet-nurse. 

Are  other  children  at  the  same  time  sick  with  any  disease, 
especially  an  infectious  one?  (This  question  is  verv  important 
for  the  diagnosis  of  acute  infectious  diseases  in  their  beginning, 
when  they  do  not  become  readily  manifested). 

Finally,  one  proceeds  to  questions  about  the  health  of  the 
parents.  How  did  the  mother  feel  during  pregnancy?  Did  the 
period  of  vomiting  last  long,  and  was  the  mother  up  until  the 
end  of  pregnancy?  What  is  the  age  of  the  parents?  Is  there  a 
close  relationship  between  them,  and  does  either  parent  suffer 
from  a  disease,  especially  one  that  may  be  communicated  by 
heredity  ?  ( Tuberculosis,  syphilis,  grave  nervous  diseases,  haemo- 
philia,  scrofulosis). 

Present  Condition. — When  through  with  the  history  one 
starts  with  the  present  condition  of  the  patient,  and  it  is  always 
necessary  to  hold  to  a  certain  course  in  order  not  to  miss  any- 
thing. One  begins,  for  instance,  with  the  gastro-intestinal  canal, 
then  follow  the  respiratory  organs,  circulatory  and  genito-urinary 
organs,  nervous  system  and  the  question  of  fever. 

Gastro-intestinal  organs.  When  asking  about  the  appetite, 
one  cannot  content  himself  with  a  short  answer — good  or  poor, 
but  should  inquire  in  detail  after  the  mode  of  life  of  the  child. 
In  which  hours,  and  what,  is  given  to  the  child  to  eat  ?  Then  it 
may  be  easily  learned  that  the  appetite  seems  to  be  poor,  while 
the  child  cats,  in  reality,  enough.  How  is  the  thirst?  Does  he 
swallow  well  and  does  he  take  the  breast  well?  Does  he  vomit 
(eructation  in  a  nursling)  or  eructate?  If  there  is  eructation  in 
a  nursling,  then  does  it  takes  place  when  the  child  becomes  dis- 
turbed (when  it  is  of  no  importance)  or  during  a  quiet  condition? 
(when  it  means  the  child  is  overfed).  If  the  baby  eructates  fifteen 
or  twenty  minutes  after  nursing,  then  is  the  milk  coagulated  ?  and 
if  immediately  after  suckling,  is  it  then  pure  (this  is  normal),  or 


24  EXAMINATION    OF    CHILDREN 

the  contrary?  (abnormal  quantities  of  hydrochloric  acid  and 
rennet  in  the  gastic  juice). 

If  there  be  vomiting,  then  when  does  it  occur — after  meals 
(gastric  vomiting)  ;  during  a  change  of  posture  (cerebral)  ;  after 
coughing  (whooping-cough)  ;  does  it  end  with  sleep  (migraine)  ; 
or  occur  during  a  severe  fever  (infectious  disease)  ? 

Does  the  child  often  move  tlie  l)(>wels?  Normall\'  mu'slings 
move  the  bowels  two  or  three  times  in  twenty-four  hours ;  after 
one  year,  at  least  once  a  day.  The  dejecta  (the  diet  being  ex- 
clusively milk)  should  be  of  jelly-like  consistency,  of  uniform 
yellow-orange  color,  odorless,  without  any  admixtures,  as  mucus, 
white  lumps,  green  color,  blood,  etc.  Any  deviation  from  the 
normal  condition  regarding  the  frequency,  consistency,  color  or 
composition  is  abnormal,  so  that  questions  must  be  referred  to 
all  these  qualities  separately,  in  order  to  ascertain  if  the  child  has 
dyspepsia  or  intestinal  catarrh,  or  follicular  enteritis. 

Does  the  diarrhoea  appear  periodically  at  a  certain  time  of  the 
day,  or  every  second  day?  (marked  malaria). 

Are  there  abdominal  pains?  (in  nurslings  attacks  of  colic). 
Do  they  occur  in  paroxysms  or  steadily"'' — and  if  in  attacks,  then 
after  or  before  meals?  ( ta])e-worms.  cardialgia),  or  ])eriodically  ? 
( intermittens  larvata ) . 

If  there  be  some  inclination  to  constipation,  then  is  the  con- 
sistency of  the  dejecta  normal  (soft,  gruel-like,  signifying  intesti- 
nal atony  or  congenital  stricture  of  the  anus),  or  hard?  (which  is, 
for  a  nursling  al)nrirmal  altogether). 

Is  the  act  of  defecation  accompanied  by  tenesmus  (constipa- 
tion, mucous  diarrhoea)  ;  by  violent  pain  (fissure  of  the  anus)  ;  or 
by  prolapsus  recti?  After  defection  are  some  drops  of  blood  ex- 
truded ?     ( polypus ) . 

Are  there  eliminated,  together  with  the  dejecta,  ta])e-wonns 
or  separate  joints  thereof? 

Is  there  itching  at  the  anus?     (oxyuris  vermicularis ). 

Respiratory  orga)is.  Is  there  snuffles  (acute  or  chronic)  ? 
In  the  case  of  acute  snuffles  is  there  a  discharge  of  muco-purulent 
fluid  (common  cold  in  the  head,  influenza,  measles),  or  a  caustic 
one  with  the  admixture  of  blood  ?  (  diphtheria  of  the  nose,  svph- 
ilis). 

In   the  case  of  chronic  rhinitis   are  both   nostrils     aft'ected 


EXAMINATION    OF    CHILDREN 


25 


(scrofula),  or  only  one  (foreign  body)?  Does  epistaxis  occur, 
and  under  what  conditions?  (after  cough  it  indicates  pertussis; 
from  unknown  causes — -habitual  nosebleed,  polvpi  of  the  nose, 
heart  failure;  periodical  epistaxis  is  suspicious  of  intermittent 
fever  (f.  larvata,  especially  if  occurring  in  the  night-time). 

Does  the  baby  cough  ?  Harsh,  ringing  (laryngitis  or  croup), 
or  a  common  cough?  Dry  (a  recent  cough),  or  wet  (resolved 
bronchitis)  ?  When  does  the  baby  cough  the  worse,  in  the  day- 
time or  in  the  night?  (This  question,  together  with  the  following, 
should  determine  whether  the  patient  has  whooping-cough). 

Does  the  paroxysm  of  cough  lead  to  flushing  of  the  face,  and 
does  it  end  with  vomiting?  Is  the  cough  accompanied  by  a 
whistling  inspiration  ?  Is  there  a  discharge  of  viscid  mucus  after 
cough  ?  When  was  the  cough  stronger,  in  the  beginning  or  at 
present?    Was  there  a  fever? 

Regarding  la  grippe  of  especial  importance  are  the  following 
questions : — Was  there  in  the  beginning  violent  fever,  snuffles 
and  shooting  pains  in  the  ear? 

Regarding  inflammatory  diseases— is  the  cough  painful  ? 

The  circulatory  organs  do  not  require  any  subjectively  ap- 
plied questions,  as  the  diagnosis  of  their  diseases  is  based  on  the 
results  of  objective  examination.  Children  almost  never  com- 
plain of  palpitation  and  pain  in  the  region  of  the  heart. 

Goiito-nrinary  organs.  Is  the  micturition  normal  regarding 
frequency?  It  is  difficult  to  say  how  often  a  normal  child  should 
pass  water,  because  the  individuality  here  plays  a  decided  role. 
Elder  children  usually  do  not  urinate  in  the  night-time.  In  the 
case  of  irritation  of  the  bladder  the  patient  urinates,  for  instance, 
every  hour  and  very  little  at  a  time. 

Is  micturition  painful  ? 

Is  the  urine  clear? 

Is  there  retention  of  the  urine,  or  z'icc  -versa,  incontinence 
during  the  night-time? 

Xcn'oiis  system.  Is  there  headache?  Is  it  of  recent  origin 
or  chronic,  often  relapsing?  Does  it  always  occur  after  mental 
exercises?  Did  it  appear  after  contusion?  The  location  of  the 
pain?     (One  temple,  viz.,  one  side  of  the  head  in  migraine). 

Are  there  other  pains? 

Are  there  convulsions?    If  so,  then  how  often  do  they  recur? 


26  EXAMINATION    OF    CHILDREN 

Are  they  accompanied  by  whistling-  inspiration  (laryngismus 
stridulus)  ?  or  by  severe  fever  (eclampsia  from  fever)  ?  or  by 
weakening  of  the  mental  capacity,  paralyses  and  other  cerebral 
symptoms  (cerebral  convulsions)  ? 

Are  there  paralyses  ? 

How  is  the  sleep  of  the  patient?  in  the  normal  condition 
infants,  as  well  as  elder  children,  sleep  the  whole  night  without 
rousing;  under  two  years  the  child  also  sleeps  in  the  day-time. 
Abnormal  sleep  is  characterized  either  by  the  child  often  awaken- 
ing, or,  after  falling  asleep  in  the  evening,  he  suddenly  wakes 
up,  jumps  in  his  bed  frightened,  looks  around  with  wide-open 
eyes,  while  he  does  not  recognize  even  the  nearest  relative,  some- 
times crying  out  the  name  of  a  thing  which  had  frightened  him 
during  his  sleep.  After  a  few  minutes  he  recovers  his  senses, 
becomes  calmed,  falls  deeply  asleep  again  and  does  not  remember 
anything  of  the  occurrence  the  next  morning.  Such  attacks, 
known  as  "night-terrors"  are  mostly  observed  in  children  from 
two  to  five  years  of  age  and  are  repeated  cither  every  evening, 
or  only  from  time  to  time. 

If  any  restless  slcej)  occurs  in  a  child  who  has  fever,  then 
this  symptom  is  invaluable ;  if,  however,  a  poor  sleep  is  of  more 
or  less  common  occurrence,  then  it  proves  the  abnormal  condi- 
tion of  the  central  nervous  system  (irritability). 

In  some  children,  about  three  years  old,  uneasy  sleep  usually 
depends  upon  general  aut'emia  (anaemia  of  the  brain),  because 
of  rachitis  or  long-continued  diarrhcea.  In  other  cases  again, 
uneasy  sleep  depends  upon  the  irritated  (dentition)  condition  of 
the  nervous  system.  In  older  children  disturbed  sleep  also  depends 
often  upon  anaemia  or  general  nervousness  (influence  of  heredity). 
In  anaemia  and  in  nervous  children  night-terror  is  of  most  fre- 
quent occurrence,  especially  when  they  have  adenoid  vegetations 
in  the  naso-pharynx. 

In  school-children  the  most  frequent  causes  of  sleeplessness 
are  forced  mental  exercises. 

Among  the  causes  of  poor  sleep  is  also  included  irritation  of 
the  bowels  by  intestinal  worms  or  by  products  of  abnormal  diges- 
tion (absorption  of  ptomaines),  or  by  stagnant  excrements  (con- 
stipation). 

Fever.     Are  fever,  chill,  or  sweatins:  noted  in  the  child? 


EXAMINATION    OF    CIIII.DRRX  2/ 

Has  fever  been  in  long^  continuance  and  how  difl  it  run  ? 

We  have  here  indicated  only  the  most  important  questions. 
It  is  conceivable  that  in  every  individual  case  still  other  addi- 
:tional  questions  will  be  required,  but  it  is  unnecessary  to  enumerate 
^11  of  them  here. 

Objective  exaisiination  and  the  significance  of  sepa- 

3RATE  symptoms. 

It  is  best  to  begin  the  examination  with  a  general  ins[)ec- 
tion  which  may  furnish  many  data  for  the  diagnosis.  During  this 
-examination  attention  should  be  given  to  the  general  countenance, 
to  the  so-called  habitus  of  the  patient,  i.  e.,  his  posture,  expres- 
sion of  his  face  and  eyes,  condition  of  the  nutrition,  peculiarity 
■of  the  skin,  character  of  respiration,  and  generally  to  every  thing 
the  eye  may  note.  If  we  have  to  deal  with  a  little  child,  then  it 
is  better  to  see  him  while  he  sleeps,  for  the  purpose  of  counting 
the  respiration  and  the  pulse  and  to  get  a  proper  idea  regarding 
i;he  color  of  the  skin,  because  all  these  symptoms  change  decidedly 
under  the  influence  of  restlessness  and  the  crying  of  the  child. 

Tlic  posture  of  the  body  may  be  involuntary  or  voluntary. 

It  is  called  involuntary  when  the  child  assumes  such  a  posture 
-instinctively,  forced  to  such  posture,  inasmuch  as  any  other  causes 
►either  pain  or  some  inconvenience. 

A  forced  posture  at  once  leads  the  physician  to  think  of  the 
corresponding  diseases,  and  together  with  other  symptoms  of  the 
habitus  it  may  plainly  point  to  the  diagnosis.  For  instance,  the 
constant  position  on  one  side  (the  diseased)  is  in  itself  very  char- 
acteristic of  a  pleuritic  exudation  (because  another  posture  would 
still  more  hinder  respiration  by  dislodging  the  mediastinum  to  the 
v^ell  side,  with  compression  of  the  healthy  lung)  ;  if,  at  the  same 
time,  we  see  that  the  patient  has  become  thin  and  pale  (meaning 
that  he  has  been  ill  for  many  days)  and  suffers  from  dyspnoea 
(accelerated  breathing,  distention  of  the  nostrils),  the  heart-beat 
•being  displaced  toward  the  opposite  side  and  the  intercostal  spaces 
being  flattened  on  the  sick  side,  then  the  diagnosis  of  abundant 
;pleuritic  effusion  may  be  made  even  without  any  examination  of 
the  thorax;  it  will  perhaps  be  necessary  to  resort  to  a  very  limited 
percussion  to  exclude  pneumothorax. 

Also  characteristic  is  an  iiiiiiiobile  f>ostiire  on  the  baeic  zcith 


28  EXAMINATION    OF    CHILDREN 

slightly  bent  legs  (in  acute  peritonitis)  ;  posture  on  the  abdomen 
(in  some  cases  of  Pott's  disease,  phlegmons  of  the  back  and  in 
case  of  severe  photophobia,  to  hide  the  face  in  the  pillow)  ;  sitting 
posture  zcith  the  head  throzvn  back  (In  cases  of  laryngeal  steno- 
sis) ;  the  posture  of  a  setter  {"en  chien  de  fusil"  of  French  authors 
— on  the  side,  rolled  up)  occurs  often  in  acute  hydrocephalus,, 
when  the  contracture  of  the  neck  prevents  the  recumbent  posi- 
tion. 

Restlessness,  manifested  by  constant  changing  of  posture,, 
is  met  with  in  severe  headache,  dyspnoea  and  high  temperatures, 
which  occur  with  delirium  and  blunted  consciousness. 

It  is  also  important  to  give  heed  to  the  expression  of  the 
face  and  of  the  eyes.  The  quick  change  of  the  color  of  the  face, 
the  motionless  look  fixed  in  the  distance,  the  icide  open,  seldom- 
zvinking  eye-lids,  are  very  characteristic  of  meningitis  and  may 
be  the  most  certain  sign  for  its  differentiation  from  typhoid. 

The  characteristic  trembling  of  the  eye-balls,  the  so-called 
nystagmus,  clinically  expressing  spasm  of  the  eye-muscles,  ap- 
pears usually  in  very  early  life,  according  to  some  authors  being 
sometimes  inherited,  and  shows  only  that  llie  vision  of  the  child 
suffers  from  the  first  months  of  life  from  any  cause.  (Small  spots- 
and  cloudiness  of  the  corneae,  congenital  cataract  or  amblyopia 
albinismus  and  pronounced  anomalies  of  refraction.  In  complete- 
blindness  nystagmus  never  develo])s.  but  atypical  movements  of 
the  eye-balls  are  observed). 

In  more  advanced  age  nystagmus  seldom  occurs.  If  this 
symptom  be  associated  with  trembling  of  the  limbs  during  volun- 
tary movements,  then  it  appears  as  strong  evidence  in  favor 
of  multiple  sclerosis  of  the  central  nervous  system. 

Bright-red  cheeks,  contrasting  with  tJie  paleness  of  the  lips,. 
chin  and  nose,  always  occur  in  scarlet  fever,  but  never  in  measles. 

Very  pale  and  puffy  face  suggests  nephritis.  However,  a 
puffy  face  with  moist  and  hypergemic  eyes  is  in  favor  of  whooping- 
cough.  The  face  is  very  characteristic  of  whooping-cough  when 
the  patient  has,  simultaneously  with  the  puffiness,  haemorrhages 
of  one  or  both  eye-balls.  A  puffy,  as  if  oedematous,  face  with 
thick  lips,  thin  hair  on  the  head,  together  with  impaired  mental 
and  physical  condition,  is  very  peculiar  of  myxoedema.  On  the- 
contrary,  a  lean  face,  with  slightly  sunken  eyes,  surrounded  by 


EXAMINATION    OF    CIIILHRF.X  29 

■blue  circles,  show  abundant  loss  of  water  by  the  org-anisni,  i.  c., 
watery,  cholera-like  diarrhoea,  or  the  desolation  of  the  arteries 
because  of  collapse  of  the  heart,  for  instance  during^  acute  peri- 
tonitis. 

Punctate,  thickly-crowded  petechia-  on  the  checks  and  espe- 
cially on  the  eye-lids  indicate  temj)orary,  but  considerable,  venous 
stagnation  in  the  skin  of  the  face  and  permit  the  supposition  of 
•either  violent  vomiting-,  or  whoopino-cough  or  an  attack  of  general 
convulsions  with  hindered  respiration. 

Jl'a.vy  paleness  of  the  face  without  any  trace  of  a^dema  in- 
dicates considerable  diminution  of  hsemogiobin  in  blood,  occur- 
ring during  chlorosis,  false  and  true  leukciemia,  malignant  an?emia, 
and  in  small  children  during  rachitis  associated  with  a  large 
tumor. 

Pallor  zcitli  yelhncish  tint  of  the  face  with  simultaneous  dark 
pigmentation  and  seborrhoea  of  eye-brows  and  long-continued 
snuffles  in  a  child  several  weeks  of  age  renders  possible  the  diag- 
nosis of  inherited  syphilis  long  before  the  appearance  of  more  char- 
acteristic symptoms. 

Senile,  wrinkled  face  in  nurslings  occurs  in  all  kinds  of 
atrophy  which  most  often  depend  upon  chronic  starvation  (lack 
-of  breast-milk  or  the  food  does  not  correspond  to  the  age),  or 
upon   chronic    diarrhcea   and    tuberculosis. 

Inz'oluntary  tz^'itchiiigs  of  different  muscles  of  the  face  cause 
the  appearance  of  peculiar  grimaces,  by  which  it  is  not  difficult  to 
recognize  chorea. 

\Mien  the  face  is  draw)i  toivard  one  side  we  recognize  a 
facial  paralysis,  and  think  first  of  all  of  a  carious  process  in  the 
temporal  bone. 

Painful  disfiguration  of  the  features  of  the  face,  occurring 
every  time  there  is  palpation  of  a  certain  part,  allows  us  to  de- 
termine exactly  the  place  of  pain. 

The  face  also  expresses  labored  breathing  (movements  of 
the  al«  nasi)  and  very  pronounced  disturbance  of  circulation  in 
the  form  of  cyanosis  of  the  lips. 

In  short  the  face  gives  to  the  physician  many  data  for  hij 
■diagnosis,  of  which  the  foregoing  are  the  most  important. 

About  the  general  nutrition  and  complexion  of  the  patient 
we  judge  from  the  development  of  the  skeleton  and  muscles,  from 


30 


EXAMINATION    OF    CIIH.DREN 


the  size  and  weight  of  the  body,  from  the  tint  of  the  skin  and" 
mucous  membranes,  from  the  amount  of  subcutaneous  fat  and 
from  the  condition  of  the  glands.  If  we  find  the  skeleton  to  be 
developed  normally,  the  muscles  being  firm  to  touch,  then  we  say 
the  baby  is  strong ;  if,  however,  the  bones  be  thin,  the  chest  flat, 
the  muscles  flabby  and  as  if  atrophied,  then  we  recognize  that  he- 
is  of  weak  constitution.  As  to  the  subcutaneous  fat,  both  its 
abundance  (obesity)  and  insufficiency  (exhaustion)  are  equally 
abnormal.  Iispecially  significant  is  a  rapid  euiaciatio)i  without 
any  visible  caus'e,  as  such  a  "groundless"  emaciation  occurs  most 
frequently  in  latent  tuberculosis,  although  it  may  depend  also  upon 
other  causes,  for  instance,  upon  rapid  growth,  loss  of  appetite 
because  of  anaemia  or  forced  mental  exercises,  and  especially  upon 
masturbation. 

By  the  external  examination  (inspection)  one  can  discover 
only  gross  defects  of  development  of  the  organism,  but  when  we 
deal  with  the  definition  of  the  primary  stages  of  malnutrition,, 
when  one  watches  the  development  of  the  child  step  by  step,  then 
inspection  alone  is,  of  course,  insufficient ;  here  are  necessary 
exact  measurements  of  the  length  of  the  body  and  its  separate- 
parts,  especially  of  the  head  and  the  chest,  as  well  as  a  determina- 
tion of  the  weight. 

All  these  means  are  resorted  to  in  all  cases  where  we  have  ta 
do  with  a  nursling  and  when  w'e  have  to  decide  whether  he  re- 
ceives a  sufficient  amount  of  food,  whether  the  wet-nurse  is  good 
and  whether  it  is  not  time  to  wean  the  child  or  to  give  additional' 
food. 

In  such  cases  the  surest  results  may  be  obtained  from  the 
regular  zveighing  of  the  cliild,  at  least  once  or  twice  a  week.  In 
view  of  the  findings  there  are  certain  normal  standards  to  be- 
taken into  consideration,  marked  deviations  from  which  are  to  be- 
held as  pathological. 

As  every  child  develops  in  his  own  way,  the  growth  of  the- 
body  never  proceeding  proportionally,  it  is,  of  course,  impossible 
to  establish  an  exact  standard,  pro|Der  for  every  body,  therefore, 
almost  every  author  having  occupied  himself  wnth  this  matter 
has  oiTered  his  own  tables  of  weight.  But  all  these  tables,  in 
my  opinion,  have  no  advantage  in  comparison  with  the  so-called 
"Bouchard's  ideal  curve"  of  the  increase  of  the   weight  of  the- 


EXAMINATION    OF    CHILDREN 


31 


body,  which  is  very  easy  to  be  kept  in  memory.  Therefore,  I  shall 
take  this  curve  as  a  standard  to  be  considered  in  estimating  the 
results  in  each  individual  case. 

The  normal  weight  of  a  new-born  is  between  2,500  and  5,000 
grams,  an  average  of  3,250  grams  (eight  pounds).  A  weight 
under  2,500  indicates  incomplete  development  of  the  child,  occur- 
ring in  abortive  children. 

During  the  first  days  after  birth  some  loss  of  weight  is  always 
to  be  expected,  reaching  its  maximum  about  the  fourth  day,  totally 


Name, Date  of  Birth,                 ISO 

Gms. 

Lbs. 

1 

2 

3 

1 

6 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

19 

20 

1120 
1310 
1200 
1080 
3970 
3850 
3710 
3C30 
3510 
3100 
3290 
3180 
3060 
2910 
2830 
2720 
2610 
2190 
2380 

9X 

9M 

»^ 

9 

«x 

8>i 

8 

7X 

7« 

7 

0 

5X 

6X 

^ 

^ 

^ 

-^ 

^ 

r-^ 

-^ 

I 

^ 

--' 

--' 

\ 

^ 

^ 

\ 

h 

^ 

^ 

\ 

<-^ 

J 

_J 

■ 

Fig.  I. — Weight  curve  of  the  first  twenty  days. 


amounting  to  about  130  to  140  grams.  Toward  the  tenth  day 
the  weight  should  rise  to  the  original  point,  otherwise  there  is 
some  abnormality.  In  firstlings,  likewise  in  abortive  children  and 
those  fed  artificially,  the  loss  in  weight  is  usually  greater  and  be- 
comes normal  later  (abortive  children,  according  to  Miller,  com- 
pensate the  loss  of  weight  usually  not  earlier  than  at  the  end  of 
the  second  week).  After  the  tenth  day  the  weight  of  the  child 
increases  progressively,  reaching  a  maximum  during  the  first  and 


32 


EXAM  IXATIOX     ()|-     C  II  II.DRKX 


second  montlis,  and  then  with  every  month  the  increase  becomes 
slower.  In  the  case  of  correct  development  the  original  weight  is 
doubled  toward  the  end  of  the  fifth  month,  and  toward  the  end 
of  the  year  becomes  trebled.     (Fig.  i.) 

According  to  Bouchard's  tables  the  increase  of  weight  occurs 
in  the  following  way : — 

Total  increase  In  one  day    Total  weight 

during    month.  gms.  g'lis.     of  child,  gms. 

Tst  750  25  4,000 

2n(l 700  23  4,700 

3rd  650  22  5,350 

4tii  <'ioo  20  5-950 

5th  550  18  6,500 

6th  500  17  7,000 

7th  450  15  ^^450 

8th  400  13  7,850 

9th  350  12  8,200 

loth  300  10  8,500 

I iLli  250  8  8,750 

I2th  200  7  8,950 

Toward  the  end  of  the  year  the  child's  weight  thus  must  be 
about  9,000  grams  (twenty-two  pounds).  This  weight  becomes 
doubled  about  the  sixth  year  (the  yearly  addition  is  about  1,500 
to  1,800  grams)  reaching  forty  to  fifty  pounds.  Then  again  after 
seven  years  it  becomes  doubled  (yearly  1,800  to  2,000  grams;  and 
after  ten  years  about  3,000  grams).     (Fig.  2.) 

The  growth  of  the  body,  head  and  chest.  The  normal  length 
of  the  newly-born  is  an  average  of  50  centimeters  (minimum  45, 
maximum  58).  Growth  is  quickest  in  the  first  months  of  life; 
the  increase  toward  the  end  of  the  year,  according  to  Quetelet, 
being  twenty  centimeters  (eight  inches)  ;  the  increase  in  the  sec- 
ond year,  ten  centimeters  (3  4-5  inches),  in  the  third  year — seven 
centimeters  (2  3-5  inches),  then  every  year  from  four  up  to  six- 
teen years — alx)ut  5.5  centimeters  (2  inches).  From  sixteen  to 
seventeen  years  the  increase  is  about  four  centimeters  (ij^ 
inches),  then  up  to  twenty-five  years  about  2.5  centimeters  (about 
one  inch)  ;  and  totally  the  increase  amounts  to  128  centimeters 
(about  50  inches),  so  that  the  normal  length  of  the  l>ody  of  an 
adult  person  rs  equal  to  178  centimeters  (about  68  inches). 

According  to  Liharzik  all  healthy  persons  grow  quite  identi- 


EXAMINATION    ()!•    CHILDREN 


33 


cally.  in  periods ;  he  defines  twenty-three  periods,  each  being- 
longer  than  the  preceding,  while  the  difference  increases  in 
arithmetical  progression  ;  the  first  period — one  month,  the  second 
— two,  the  third — three,  etc.  During  any  period  under  the  twenty- 
first  month  (the  end  of  the  sixth  period)  the  length  of  the  body 
increases  about  'jYj  centimeters  (about  three  inches),  the  circum- 
ference of  the  head — 2y2  centimeters  (one  inch),  that  of  the 
chest — 2V2  centimeters.     After  twentv-one  montlis  the  growth  is 


I^atne, 

WEIGHT  CHART. 
Date  of  Birth 

rSo 

■^ 

i 
0 

_l 

MONTH  OF  AGE. 

1         2         3         4         5         6         7         8         9        10       11      12 

lOSiW 
IU30 
W80 
9630 
9070 
8S20 
C1«0 
7710 
7800 
6800 
63fiO 
S»00 
UM 
«990 
UM 
MWO 
3630 
3180 
2720 
2Z70 

21 
23 
22 
21 
20 
10 
18 
17 
16 
15 
U 
13 
12 
11 
10 
9 
8 
7 
0 
6 

~ 

'~ 

"■ 

1 

— 1 

, 

** 

'' 

< 

■^ 

^ 

». 

* 

■ 

■* 

,. 

«  "^ 

^' 

_  ** 

^^ 

,>" 

> 

/ 

/ 

/ 

/ 

/ 

/ 

- 

- 

- 

/ 

4 

f 

/ 

^ 

- 

.- 

_^ 

_j 

^ 

_ 



1  1 

Fie 


Tlu 


In  curve  of  the  first  year. 


much  slower;  the  length  of  the  body  increases  only  five  centi- 
meters (2  inches)  during  each  period,  the  circumference  of  the 
head,  13-24  centimeters,  that  of  the  chest  13-24  to  ix-17  centi- 
meters; from  twelve  years  (the  eighteenth  period)  the  growth  of 
the  chest  increases  considerably ;  the  amount  of  the  increase  is  for 
each  period  13-24+5  centimeters  (2  inches)  growth  of  the  body. 


34 


EXAMINATION    OF    CITII.DREN 


All  these  data  are  expressed  in  the  following  table 


Peri- 

The 

The 

The 

The 

The  cir- 

The cir- 

The 

ods. 

lumber 

j^rowth 

growth 

growth 

cumference 

cumfereuce 

length 

in 

of  the 

of  the 

of  the 

of  the 

of  the 

of  the 

of  the 

order. 

mouths. 

head. 

chest. 

body. 

head. 

chest. 

body. 

cm. 

cm. 

em. 

cm. 

cm. 

cm. 

1 

1 

2¥j 

214x13-17 

Ji/.- 

371/2 

36    9-34 

••57  Mi 

2 

3 

2V2 

2  1^x13-17 

7 '  •> 

40 

39  18-34 

65 

3 

(j 

2% 

214x13-17 

71/j 

421/0 

42  27-34 

72  V, 

4 

10 

21/2 

214x13-17 

7'/.. 

45 

46    2-34 

80 

;") 

15 

2V^ 

214x1317 

714 

47'/. 

49  11-34 

871/2 

6 

•Jl 

21/0 

214x13-17 

71/j 

a> 

52  20-34 

95 

7 

28 

13-34 

13-34x13-17 

5 

50  i3-:i4 

.53  25-:}4 

KM) 

8 

3(i 

13-34 

13-34x13-17 

r^ 

50  26-:i4 

54  30-34 

1(15 

9 

45 

13-34 

13-34x13-17 

r 

51     1-34 

5(i    1-34 

110 

10 

55 

13-34 

13-34x13-17 

5 

51  18-34 

57   2-:^ 

115 

11 

66 

13-34 

13-34x13-17 

5 

51  31-34 

5S  11-34 

120 

12 

78 

13-34 

1:;  ::4-i3-i7 

5 

52  10-34 

50  16-34 

125 

13 

ni 

13-34 

i:;  ;!J1:m7 

5 

52  20-34 

t>o2i-:u 

130 

14 

105 

13-34 

1:!  .-ui:;  17 

5 

53    2-34 

61  26-34 

135 

15 

120 

13-34 

i:',-34- 13-17 

5 

53  15-34 

62  31-34 

140 

16 

136 

13-34 

13  341:M7 

5 

53  28-34 

M  28-;i4 

145 

17 

153 

13-34 

13  34,<KM7 

5 

54    7-34 

65  ~-:u 

150 

18 

171 

13-34x5 

54  20-^ 

70  20-;^4 

155 

19 

IftO 

1 

54  33-34 

75  33-34 

160 

20 

210 

55  12-34 

81  12-34 

163 

21 

231 

55  25-34 

86  25-34 

170 

22 

253 

56    4-34 

92    4-34 

175 

23 

276 

56  V^ 

9714 

180 

(Tv, 

enty-threc 

^  years.) 

♦211/, 

*64i/. 

•130 

•Averjijre  Increase. 


The  circumference  of  the  head  of  a  new-born  is  from  34 
to  35  cm.  (about  14  to  15  inches),  that  of  the  chest  (on  the  level 
of  the  nipples)  32  to  33  cm.  (  12  to  13  inches). 

As  not  all  children  grow  with  ecpial  rapidil\ .  and  many  that 
are  entirely  healthy  develop  slowly,  then  the  knowledge  of  the 
absolute  numbers  of  growth  is  \et  insufficient  for  admitting  the 
development  of  any  given  child  to  be  normal  or  pathological. 

In  this  regard  more  interesting  conclusions  may  be  drawn 
from  the  comparison  of  the  size  of  the  head  with  that  of  the  chest 
and  the  length  of  the  body ;  therefore  we  gave  in  the  table  all  these 
numbers   side  by  side. 

The  too  rapid  growth  of  the  body  is  of  especial  significance 
when  it  does  not  correspond  to  the  increase  of  the  body  in  width, 
i.  e.,  the  circumference  of  the  chest  and  the  width  of  the  shoulders. 

The  breadth  of  flie  shoiihiers  tiiiist  in  all  periods  of  growth 
be  equal  to  one-fourth  of  the  length  of  the  body;  for  instance, 
according  to  Ufifelmann : 


EXAMINATION    OF    CIlll.DRF.X 


35 


The  breadth  of  the  Length  of  the 
shoulders.  Ixxlv. 

Years.  cm.  cm. 

o 13-7  50 

3    ^3  87 

6  32  122 

14  •■  ■•" 3^>  150 

In  a  normally  developed  new-born  child  the  circumference 
of  the  head  exceeds  that  of  the  chest  by  from  one  to  two  centi- 
meters (about  half-an-inch  to  one  inch)  ;  the  size  of  the  chest  ex- 
ceeds the  half  of  the  length  of  the  body  by  nine  to  ten  centimeters 
(about  four  inches),  minimum  of  seven  centimeters  (three 
inches).  If  the  difference  between  the  head  and  the  chest  is 
greater  than  two  centimeters  (one  inch),  and  that  between  the 
chest  and  the  half  of  the  body  less  than  seven  centimeters  (three 
inches),  then  this  points  to  congenital  weakness  of  the  child, 
his  reduced  vitality. 

Generally  speaking,  the  stronger  the  constitution  of  the  child 
the  more  his  chest  equals  the  head  in  dimensions ;  the  weaker  the 
child  the  more  the  head  prevails  in  size. 

It  follows  from  Liharzik's  table  that  the  circumference  of  the 
chest  becomes  equal  to  that  of  the  head  toward  the  end  of  the  first 
half  of  the  year ;  but  in  reality  such  a  growth  of  the  chest  is  a  quite 
rare  occurrence,  being  only  observed  in  the  most  robust  children. 
In  the  majority  of  healthy  children  the  chest  begins  to  exceed  the 
head  only  in  the  third  year;  in  feeble  and  rachitic  children  during 
the  fifth  or  the  sixth  year. 

Regarding  the  length  of  the  body  we  noticed  that  the  circum- 
ference of  the  chest  must  exceed  that  of  the  half  of  the  body 
at  least  by  seven  or  eight  centimeters  (three  to  three-and-a-half 
inches),  an  average  of  ten  centimeters  (four  inches).  This  differ- 
ence gradually  vanishes  during  the  first  years  of  life  and  descends 
to  zero  by  the  seventh  or  eighth  year;  after  that  the  circumfer- 
ence of  the  chest  begins  to  remain  behind  the  half-growth,  the 
difference  in  favor  of  the  latter  reaching,  at  twelve  years,  two  to 
four  centimeters   (one  to  two  inches). 

The  better  the  child  is  developed — the  stronger  he  is — so  com- 
paratively larger  is  the  circumference  of  his  chest.  The  latter 
•exceeds,  in  children  about  ten  vears  old.  the  half-growth  of  the 


36  EXAMINATION    OF    CHILDREN 

body  bv  four  or  five  centimeters  (two  or  two-and-a-half  inches) 
and  becomes  even  only  toward  fourteen  or  fifteen  years. 

If  the  primary  weight  of  the  body  be  under  300  grams  (seven 
pounds ) ,  the  dimensions  of  the  head  and  chest  being  of  the  above 
said  form,  it  means  the  child  was  born  weak  ;  if,  however,  all 
those  sizes  are  above  the  normal  average,  then  the  child  was  born 
robust. 

We  speak  of  children-giants  when  the  weight  exceeds  at 
birth  500  grams   (twelve  pounds). 

The  largest  weight  at  birth,  learned  from  literature,  (x:curred 
in  Dr.  Wisin's  practice  (9,000  grams,  or  twenty-one  pounds). 

The  under- weight  of  the  new-born,  or  its  general  atrophy, 
either  indicates  that  he  is  an  abortive  child,  or  (if  born  at  full 
term)  that  his  nutrition  during  uterine  life  was  abnormal  because 
of  disease  of  the  mother  (most  often  syphilis),  or  disease  of  the 
placenta. 

Atrophy  occurring  in  children  born  healthy  and  robust  is 
usually  caused  by  chronic  starvation  : — this  is  simple  or  true 
atrophy. 

The  causes  of  emaciation  in  other  cases  are  some  chronic 
diseases,  most  often  diarrhrea  and  general  tuberculosis : — this  is 
symptomatic  atrophy. 

Simple  atrophy  as  an  entirely  independent  disease,  i.  e.,  one 
wdiich  is  not  caused  by  intestinal  catarrh  or  other  diseases  of  the 
viscera,  occurs  only  in  children  during  the  first  months  of  life, 
and  by  its  aetiology,  symptomatology  and  thera])y  must  be  decided- 
ly  distinguished  from  symptomatic  atro])hy  as  the  result  of  ex- 
hausting diseases.  The  aetiology  of  pure  atrophy  is  traceable  to 
chronic  starvation,  no  matter  whether  it  depends  upon  lack  of 
milk  in  the  nursing  woman,  or  upon  abnormal  artificial  feeding 
by  small  quantities  of  diluted  milk,  or  by  food  which  is  altogether 
improper  to  the  child's  age  so  that  it  cannot  be  assimilated. 

Symptoms  of  any  form  of  atrophy  are  manifested  by  general 
emaciation  of  the  organism,  consisting  especially  in  the  complete 
disappearance  of  the  sulxutaneous  fat,  and  with  flabbiness  or 
folding  of  the  skin.  In  children  of  the  earliest  months  of  life 
there  is  also  among  the  characteristic  symptoms  a  depression  upon 
the  top  of  the  skull  because  of  diminution  of  the  brain :  the  large 


EXAMINATION    OF    C  1 1  I  I.DRKX 


37 


fontanclle  is  deeply  (le|)ressc(l  and  the  l)()nes  of  the  skull  slide  over 
each  other. 

Simple,  uncomplicated  atroph\-  ditters  from  the  syui]:)toniatic 
variety  caused  by  chronic  diarrhoea  1)\'  the  following  peculiari- 
ties : — 

(  I )  It  develops  most  often  during  the  first  four  months  and 
very  seldom  after  six  months ;  while  the  symptomatic  form  ap- 
pears later. 

(2)  Instead  of  diarrhcea  and  distended  abdomen  there  usually 
is  constipation,  the  belly  being  sunken  and  flattened  and  the  urine 
scanty  (see  the  section  on  Constipation). 

(3)  There  is  never  redema  of  the  suljcutaneous  tissue,  which 
seldom  fails  (around  the  malleoli )  in  emaciation  caused  by 
diarrhoea. 

If  simple  atrophy  be  complicated  by  intestinal  catarrh  ( which 
happens  not  infrequently,  especially  if  the  atroph\-  arises  under 
the  influence  of  improper  nourishment),  then  considerable  ex- 
pansion of  the  belly  may  also  occur,  so  that  for  the  correct  esti- 
mation of  the  case  there  remain  the  first  and  the  third  criteria  and 
the  history  (if  considerable  emaciation  began  before  the  diarrhcea  : 
inquiry  after  the  previous  feeding  of  the  ch.ild  and  about  its 
amount;  examination  of  the  breasts  of  the  mother  in  regard  to  the 
quantity  of  milk). 

Symptomatic  atrophy,  met  with  sometimes  in  grave  cases  of 
rachitis,  diiTers  from  the  genuine  form,  not  only  in  the  child's  age, 
but  by  the  symptoms  of  pronounced  rachitis.  The  last  circum- 
stance obtains  especial  diagnostic  value  in  view  oi  the  interesting 
fact,  found  by  Bohn,  that  children  sufifermg  from  simple  atrophy 
do  not  manifest  any  disposition  to  rachitis,  so  that  even  softening 
of  the  occiput  is  then  absent. 

The  most  difficult  to  distinguish  is  simple  atrophy  from 
tuberculosis  of  small  children,  especially  when  the  atrophy  be- 
comes complicated  by  bronchitis  or  pneumonia,  which  is  so  often 
to  be  met  with.  On  the  other  hand  even  the  absence  of  cough 
does  not  exclude  tuberculosis.  If  simple  atrophy  may  be  ex- 
cluded on  the  ground  of  the  anamnesis  and  no  visible  causes 
be  found  for  the  explanation  of  the  marasmus,  then  tuberculosis 
is  to  be  suspected,  and  we  must  try  to  confirm  it  b\  the  febrile 
condition  and  heredity. 


38  EXAMINATION    OF    CHILDREN 

Inspecting  the  skiu  one  must  pay  attention  to  its  color  and  tO' 
possible  eruptions.  ( See  the  section  on  the  Senieiology  of  the 
Skin). 

About  the  condition  of  the  lymphatic  glands  we  get  an  i;lea 
by  inspection  and  palpation  of  the  neck,  axillae  and  groins.  In 
entirely  healthy  children,  the  subcutaneous  tissue  being  moderately 
developed,  the  lymphatic  glands  cannot  be  palpated.  Chronic  en- 
larged glands,  evident  to  a  common  e-xamination,  indicate  a  serious 
disorder  of  the  general  nutrition  (tuberculosis,  true  or  false 
leukaemia,  or  at  least  a  pronounced  scrofula),  in  the  case  of 
niicropolyadcnisni,  i.  e..  when  one  can  palpate  at  the  nape  of  the 
neck,  in  the  axilUe  and  groins,  a  great  number  of  glands,  solid, 
movable,  painless,  small  (from  the  size  of  a  hemp-seed  to  that  of 
a  coffee-bean),  we  may  draw  a  conclusion  about  tlie  weakness  of 
the  lymphatic  glands,  i.  e.,  abinit  their  vulnerability  in  the  sense 
of  being  ])rone  to  hyperplasia  and  caseous  degeneration.  Such 
patients  we  hold  as  scrofulous,  liable  also  to  hyperplasia  of  the 
internal  glands  as,  for  instance,  the  bronchial.  In  the  opinion 
of  some  French  authors,  micropolyadenism  and  swelling  of  the 
spleen  in  pale  and  marasmic  children  are  certain  signs  of  general 
tuberculosis.  At  any  rate  one  must  not  become  much  discouraged 
by  the  presence  of  micropolyadenism,  as  this  symptom  may  alsa 
occur,  besides  in  tuberculosis,  during  other  forms  of  marasmus, 
for  instance,  under  the  inlUience  of  chronic  diarrhrea.  svphilis  and 
bronchopneumonia. 

.Vssociation  of  micropolyadenism  with  swelling  of  the  spleen, 
and  often  of  the  liver,  indicates,  at  any  rate,  considerable  exhaus- 
tion of  the  organism. 

Micropolyadenism  occurs  most  often  in  children  of  early 
age,  those  of  five  or  six  years. 

Examination  of.  the  head  is  carried  out  by  inspecting,  pal- 
pating and  measuring.  Attention  is  to  be  given  to  the  shape  and 
size  of  the  head,  the  condition  of  the  sutures  and  fontanelles,  the 
hardness  of  the  bones  and  the  condition  of  the  skin. 

The  head  of  a  normal  child  must  have  an  oval  form,  without 
any  pronounced  character  of  the  parietal  and  frontal  protuber- 
ances, and  entirely  symmetrical.  The  bones  of  the  skull  must  be 
solid,  neither  yielding  to  pressure  by  the  finger  even  on  the  sutures 
or  at  the  point  of  the  frontal  fontanelle.    The  latter  remains  often. 


EXAMIXATIOX    OI'    (11  1  l.l1Ki;.\ 


39 


until  the  twelfth  to  the  sixteenth  months,  however  the  lambdoidal, 
sag-ittal  and  coronal  niav  he  felt  not  later  tliaii  before  the  end  of 
the  third  month. 

About  the  size  of  tlie  head  of  the  new-born,  its  increase  ac- 
cording to  the  age.  and  about  the  relation  of  the  circumferences  of 
the  head  and  the  chest.  I  have  already  spoken. 

Deviations  fron:  the  normal  condition  may  be  manifold.  Ir- 
regular, ang-ular  shape  of  the  head,  because  of  abnormal  growth 
of  the  parietal  and  frontal  protuberances,  points  toward  rachitis, 
in  the  highest  degree  of  which  the  head  becomes  saddlc-shapcd. 
This  form  is  characterized  by  flattening  of  the  skull  imd  bv  a  con- 
siderable development  of  the  protuberances,  while  depressions  are 
to  be  seen  in  those  places  of  the  skull  which  correspond  to  the 
sutures. 

A  slight  asyiiniictry  of  the  skull  in  the  form  of  some  flatten- 
ing of  one  side  ( usually  in  the  region  of  the  connection  of  the 
parietal  bone  with  the  occipital )  occurs  very  often  in  small 
children,  depending  uix)n  the  constant  lying  of  the  child  on  one 
side.  Such  an  asymmetry  has  no  importance  ( pathological ) .  s(jon 
disappearing  if  care  be  taken  that  the  child  should  not  lie  upon  one 
side.  Another  thing  are  the  highest  degrees  of  asymmetry  which 
depend  upon  the  early  ossification  of  the  sutures  of  one  side  of  the 
head,  or  upon  the  congenital  maldevelopment  of  one  hemisphere. 

If  the  circitmference  of  the  chest  in  the  first  year  of  life  is 
much  larger  than  that  of  the  head,  then  this  indicates  maldevelop- 
ment of  the  head  (microcephalia),  being  a  reason  for  fearing 
future  idiocy.  (  )n  the  contrary,  if  the  head  be,  in  comparison  with 
the  chest  and  the  age.  too  large,  then  is  the  child  suiTering  either 
from  rachitis,  with  simple  sinutltaneous  hypertrophy  of  the  brain, 
or  chronic  hydrocephalus.  Chronic  hydrocephalus  is  usually  a 
cc^ngenital  malady  and  consists  in  accumulation  of  fluid  in  the 
cerebral  ventricles.     With  advancing  age  it  usually  increases. 

Franz  Mayr  differentiates  the  characteristic  features  of  hyper- 
trophy of  the  brain  and  those  of  the  hydrocephalus  in  the  fol- 
lowing table  :  (  *  ) 

*Franz  Mayr:  Jarbiichcr  fi'ir  Kiudcrh.     I.  B.  S.   15. 


40 


EXAMINATION    OF    CHILDREN 


Hypertrophy  of  the  Brain.  Hydrocephalus  chronicus. 

The  shape  of  the  skull: 
Wide,  angular  with     eminent  Spheroidal,       witliout     any 

frontal  and  occipital  protuber-  pronounced  eminences, 

ances. 

Enlargement  of  the  skull 
Develops  very  slowly,  almost    •  Develops  rapidly,  so  that  a 

imperceptibly,   and   never  be-  visible  increase  of  the  diame- 

comes  so  considerable  that  the  ters  may  be  noticed  even  after 

face  is,  in  comparison  with  the  two  weeks:  the  face,  in  com- 

skull,  disproportionally  small.  parison  with  the  skull,  is  pro- 

portionally '^mall. 

The  anterior  foutauelle 
Is   larocr   than    normal ;   it   is  /  'ery   lari;c.  protruded   and 

elevated  and  ])ulsates  intense-  does  not  pulsate  at  all.  or  very 

ly.  little. 

The  hones 
Are  movahle  at  the  location  of  Are   connected   by   membran- 

the  sutures,  but  somewhat  dis-  ous.  tense  interspaces, 

connected. 

Coinplications. 
Traces  of  bc.i^innint;- rachitis  Retarded     development      of 

in  the  rest  of  the  skeleton.  the  bones  and  muscles. 

Laryngismus  stridulus.  General  convulsions. 

Mental  development. 
Occurs  normally,  sometimes  Hindered,  at  least  in  sepa- 

remarkably  well.  rate  forms.     Often  idiocy. 

The  conse(]uenees  of  compression  of  the  brain 
Imperceptible,  if  in  the  l)eg-in-  Are  always  present.  \^omit- 

ning  of  the  disease  the  fonta-  ing,  heaviness    of    the    head, 

nelle  was  still  open.  tremor  on  motion,  strabismus, 

wide  pupils,  tonic  spasm  in  the 

legs.  etc. 

Softening  of  the  skull-bones  may  be  inherited  or  acquire<l. 
In  the  former  case  it  is  not  pathological  (with  which,  however, 
not  all  authors  agree)  and  disappears  quite  rapidly  after  de- 
livery; in  the  latter  it  is  held  as  a  s\-mptom  of  rachitis,  namely, 
of  its  initial  period.  Inherited  softening  of  the  bones  is  mostly 
to  be  seen  during  the  first  da}"S  of  life  :  soft  parts  are  usually 
located  along  the  sagittal  suture.  The  acquired  or  rachitic  soft- 
ness of  the  bones  appears  during  the  third  or  fourth  months  of 


EXAMINATION    OK    CIIILDRICX  4I 

life,  remaining  often  unnoticed  until  the  end  of  the  year,  or 
until  the  ninth  month.  Soft  places  occur  in  the  occiput  (soften- 
ing of  the  occiput — craniotabcs),  appearing  in  mild  cases  as  sepa- 
rate islets,  in  grave  instances,  however,  almost  the  whole  of  the 
•occipital  bone  becoming  soft. 

]t  is  not  difficult  to  recognize  softening,  because  it  vields 
like  parchment  when  one  presses  on  the  soft  place  with  the  finger. 
In  order  not  to  overlook  even  a  small  island  of  softening  it  is 
Tjest  to  examine  the  child  while  he  is  in  the  recumbent  posture. 
The  physician,  standing  at  his  feet,  places  both  his  hands  in  such 
a  manner  that  the  thumbs  rest  on  the  forehead,  the 'fingers  pal- 
pating the  occiput.  Pressure  upon  all  points  of  the  occiput  is 
then  made  by  the  ends  of  the  slightly  bent  fingers. 

Softening  of  the  occiput  occurs  especially  often  in  rachitic 
■children  suffering  from  laryngo-spasms  (laryngismus  stridulus). 

Anomalies  of  the  fontanellc  and  sutures.  During  the 
iirst-nine  months  the  anterior  fontanelle  may  gradually  increase 
in  size  even  in  entirely  healthy  children.  Such  an  increase  is 
normal  if  the  distance  between  the  opposite  sides  of  the  square 
(i.  e.,  margins  of  the  fontanelle)  does  not  exceed  1.5  to  2  centi- 
meters (about  one  inch),  but  it  must  gradually  decrease  in  size 
■during  the  last  quarter  of  the  year  and  be  closed  entirely,  i.  e., 
ossified,  toward  the  sixteenth  month.  The  retarded  closure  of 
the  fontanelle  and  sutures,  or  abnormally  large  size  of  the  fon- 
.tanelle,(i.e.,if  it  be  larger  than  2  by  2  centimeters,  being  independent 
of  chronic  hydrocephalus),  points  toward  some  interference  with 
ossification,  as  rachitis.  Abnormal  or  delayed  dentition  (see  the 
section  on  Dentition )  and  other  signs  of  rachitis,  usually  also 
coincide  with  this,  which,  however,  are  not  necessarily  present, 
because  rachitis  may  be  limited  during  the  first  year  of  life  only 
to  the  skull. 

The  projected  fontanelle  indicates  increased  pressure  in  the 
skull  cavity;  the  sunken  fontanelle — decreased  pressure  and 
diminution  of  the  brain.  If  the  fontanelle  be  intensely  sunken, 
-combined,  in  children  during  their  first  months  of  life,  with  slid- 
ing of  the  scalp-bones  over  each  other  (the  edge  of  the  occipital 
bone  coming  under  the  parietal  bones)  it  is  a  very  valuable 
diagnostic  sign  between  acute  hydrocephalus  and  hydrocephaloid, 
-particularly  in  favor  of  the  latter. 


42  EX.\MINATION    OF    CHll.DREN 

Slightly  projected  ami  bulgi)ig  foniancUc  indicates  hypergemia 
of  the  brain  (usually  accompanied  by  violent  fever)  ;  while  a 
projected  and  tense  fontanelle.  that  is,  not  easily  yielding  to 
pressure  by  the  hnger,  indicates  an  exudation  in  the  cavity  of 
the  skull,  of  whatever  kind  it  nia}-  be — purulent  meningitis  of  the 
surfaces  of  the  hemispheres,  or  acute  hydrocephalus,  or  an  inter- 
meningeal  haemorrhage  in  the  new-born.  The  significance  of  this 
symptom  is  still  iiuportant  by  excluding  a  common  over-filling  of 
the  vessels,  because  a  convex  and  tense  fontanelle  is  found  neither 
in  active  nor  in  passive  hyperemia  of  the  brain.  Therefore,  the 
condition  of  the  fontanelle  may  be  of  decided  importance  in  many 
doubtful  cases,  when  the  question  luust  be  decided  whether  the 
cerebral  symptoms  (vomiting,  stupor,  convulsions)  depend  in 
the  given  case  upon  causes  outside  of  the  cavit\  of  the  skull  (very 
high  temperature,  acute  pneumonia,  nephritis  with  uraemia),  or 
upon  a  genuine  lesion  of  the  brain.  Of  still  greater  importance 
is  this  symptom  in  those  cases  where  from  the  course  of  the 
disease  and  general  marasmus  of  the  child  a  sunken  fontanelle 
would  be  expected,  but  where  the  contrary  is  observed,  as  occurs 
usually  during  acute  hydrocephalus. 

If  a  projected  and  resistent  fontanelle  be  noticed  in  a  nciv- 
horn,  and  if  it  does  not  pulsate  at  all,  then  an  abundant  inter- 
meningeal  haemorrhage  may  be  suspected. 

In  auscultation  of  the  fontanelle  one  succeeds  in  hearing,  in 
some  children,  a  bloiving  murmur,  synchronous  with  the  pulse 
and  arising,  according  to  Jurasch,  in  the  carotid  artery  being 
slightly  compressed  in  the  carotid  canal  of  the  temporal  bone. 
This  murmur,  in  the  opinion  of  authors,  has  no  pathological 
significance,  although  occuring  in  rachitis  oftener  than  in  healthy 
children.  According  to  our  observations,  the  "cerebral  murmur" 
occurs  especially  often,  being  comparatively  more  intensive  in 
anaemic  children,  in  whom  one  succeeds  in  noting  simultaneous 
venous  murnuirs  below  the  clavicles,  as  well  as  murmurs  in  the 
mastoid  processes  of  the  temporal  bones,  and  at  the  neck  just 
below  the  occipital  bone.  We  regard  the  last  named  murmurs,  as 
well  as  the  murmur  in  the  fontanelle,  as  arising  in  the  venous 
sinuses. 

Examination  of  the  skin  of  the  head.  Baldness  of  the  oc- 
ciput, together  with   sweating  of   the  head,  are  frequently  met 


KXA.MINAI  ION    OF    CIIILDRKX 


43 


with  ill  craniotabes,  having-  the  same  importance  as  the  latter 
( ^ee  page  41).  The  skin  of  the  head  is  the  favorable  place  of 
numerous  eruptions.  In  small  children  crusts  arc  often  met  with 
from  seborrhoea  and  eczema,  and  in  elder  ones  from  eczema  and 
parasites  (lice,  herpes  tonsurans,  favus).  About  the  diagnosis 
of  such  eruptions  see  the  part  on  the  Semeiology  of  the  Skin. 

TtDiiors  of  the  head  occur  especially  often  in  new-bom  chil- 
dren. During  the  first  two  days  after  birth  there  appears  a 
diffuse  tumor  of  the  soft  parts  because  of  oedema,  and  of  the  part 
of  presentation  being  infiltrated  with  blood.  Such  a  tumor,  known 
as  caput  succcda)icu)u  (additional  head),  disappears  very  soon 
after  labor  and  is  therefor  of  no  importance.  From  all  other 
tumors  it  differs,  besides  this,  by  its  doughy  consistency,  oedema- 
tous  character  (a  dimple  remains  on  pressure  with  the  finger), 
bluish  tint  of  the  skin  and  by  its  spreading  margins.  It  may 
occupy  any  part  of  the  skull  and  does  not  bear  any  relation  to 
the  sutures. 

Blood-tumor  of  the  head  (^cephalh?ematoma),  the  result  of 
h?emorrhage  between  the  bone  and  its  periosteum,  arises  also 
under  the  influence  of  labor,  but  does  not  appear  immediately 
after  the  child's  birth,  like  the  preceding  tumor,  but  after  two  or 
three  days.  It  continues  to  increase  during  the  first  period,  then 
remains  stationary  for  a  few  days  and  slowly  vanishes  in  from 
four  to  twelve  weeks.  The  size  of  the  tumor  is  that  of  a  walnut,  or 
larger ;  it  is  covered  with  the  normal  skin,  has  a  sharply-defined 
border  and  fluctuates.  It  is  especially  characteristic  of  this  tumor 
that  it  never  crosses  the  suture  (because  the  periosteum  is  here 
firmly  adherent  and  cannot  be  separated  by  the  extravasated 
blood).  The  favorable  situation  of  these  tumors  is  the  midst 
of  the  parietal  bones  of  one  or  both  sides.  The  base  of  the  tumor 
becomes,  after  several  days,  surrounded  by  a  distinctly  palpable, 
solid  border  (proliferation  of  the  periosteum). 

In  older  children  cephalhsematoma  also  appears  sometimes 
in  the  form  of  a  sharply-defined,  elastic,  slightly-fluctuating 
swelling  (usually  on  the  forehead),  but  exclusively  from  contu- 
sion ;  therefore  the  skin  is  generally  covered  with  ecchymoses, 
and  one  of  them  usually  remains  in  the  place  of  the  tumor. 

A  fluctuating,  circumscribed  tuiuor  on  the  child's  skull  may 
depend  also  upon  an  abscess,  and  a  cerebral  hernia  as  well.    Acute 


44  EXAMINATION    OF    ClIir.HREN 

abscesses  may  be  easily  distinguished  l)v  their  painfuhiess  and 
the  redness  of  the  skin ;  however,  in  cold  abscesses  the  coverings 
remain  normal,  there  is  no  pain,  the  abscess  is  not  connected  with 
sutures  and  differs  in  its  aetiology  (usually  because  of  caries, 
thus  in  scrofulous  and  syphilitic  children,  as  well  as  in  pyaemia)  ; 
by  the  age  (cold  abscesses  do  not  occur  on  the  head  of  a  new- 
born), and  by  the  absence  of  a  solid  border  around  the  base  of  the 
tumor. 

Cerebral  hernia  in  contrast  with  the  preceding  forms  always 
occurs  at  the  location  of  a  suture,  most  often  at  the  base  of  the 
nose  (glabella)  or  on  the  occiput.  'I'Ik'  tumor  has  commonly 
a  baggy  form  with  a  narrow  base.  It  contains  either  onlx-  fluid — 
hydromeningocele,  or  also  brain  substance — encephalocelc. 

The  former  fluctuates  and  is  transparent,  the  latter  docs  not 
fluctuate  but  sometimes  pulsates.  ( )ne  may  in  both  cases  feeJ 
at  the  base  of  the  tumor  the  margin  of  the  bone-opening,  through 
which  the  hernia  has  protruded.  If  the  opening  be  large  enough 
the  tumor  may  be  somewhat  reduced,  and  then  there  api)ear 
symptoms  of  increased  pressure  in  the  cavit\  of  the  skull — pro- 
trusion and  tension  of  the  fontanelle,  and  sometimes  general  con- 
vulsions. 

Cerebral  hernia  becomes  tense  during  the  crying  of  the  child 
and  this  symptom,  among  others,  may  serve  for  the  distinction 
of  this   tumor  from   congenital   sarcoma  or  lipoma. 

If  a  fluctuating  tumor  on  the  skull  be  recognized,  according 
to  all  signs,  as  a  cerebral  hernia,  yet  does  not  become  tense  during 
the  cry  and  cannot  be  decreased  1)\  ])ressure,  then  one  must 
expect  a  very  small  opening  m  the  bones  of  the  skull,  which  would 
lead  to  hope  for  a  favorable  result  of  operation  in  such  hernia. 

From  the  inherited  cerebral  hernia,  known  also  under  the 
name  of  true,  we  must  distmguish  an  acquired  one,  traninatic, 
or  false,  hernia  cerebri.  The  formation  of  such  meningocele 
spuria  involves  two  conditions : — First,  a  violent  trauma  with 
fracture  of  the  skull  and  rupture  of  the  dura  mater ;  secondly, 
the  integrity  of  the  coverings  of  the  scalp.  As  both  these  condi- 
tions much  easier  take  place  at  an  early  age,  therefore,  false 
cerebral  herniae  almost  always  arise  because  of  contusion  during 
the  first  or  second  year  of  life.  The  cerebro-spinal  fluid  accumu- 
lates then,  through  the  ruptured  dura  mater  and  the  split  of  the 


EXAM  IN  ATM  i.\     l)!'    (   1 1  I  LI  )Ki;.\  45 

skull,  beneath  the  periosteum,  and  in  case  of  rupture  of  the  latter 
— beneath  the  aponeurosis,  so  that  there  is  formed  a  sliarply- 
defined,  tluctuating,  sometimes  pulsating  tumor,  which  becomes 
tense  during"  the  cry,  ]>eing-  covered  with  normal  skin ;  in  short, 
a  tumor  very  similar  to  a  brain  hernia.  The  diag'nosis  may  be 
corroborated  by  the  possibility  of  palpating,  at  the  base  of  the 
tumor,  the  margin  of  the  bone-opening  and  of  reducing,  or  at 
least  decreasing,  the  tumor  by  a  moderate  force,  while  symptoms 
of  brain  pressure  may  appear. 

However,  it  is  not  difficult  to  distinguish  between  the  true 
and  false  hernije ;  besides  the  history,  the  place  occupied  by  the 
tumor  positively  indicates  what  the  trouble  is ;  the  false  brain 
hernia  is  never  located  on  a  suture,  but  always  on  the  bone  itself, 
generally  upon  one  of  the  parietal  bones. 

In  elder  children  there  sometimes  occur  on  the  scalp  circum- 
scribed periostites,  simple,  purulent,  and  sarcomatous  tumors. 

The  examination  of  the  month  and  fauces  is  performed  by 
inspection,  for  which  purpose  one  must  sometimes  forcibly  open 
the  child's  mouth.  In  new-born  children  and  nurslings  it  suffices 
to  make  a  slight  pressure  on  the  chin  by  the  finger,  but  in  children 
three  to  live  years  old  the  physician  sometimes  meets  a  resistance 
on  the  part  of  the  child  not  easy  to  overcome.  In  many  cases  one 
succeeds  in  making  the  child  open  the  mouth  by  means  of  com- 
pressing the  nostrils,  but  this  does  not  always  follow,  because 
some  children  contrive  to  breath  through  the  slits  of  the  teeth. 
In  such  cases  one  must  introduce  the  handle  of  a  tea-spoon  be- 
tween the  cheek  and  the  teeth  behind  the  last  molars  and  then  turn 
the  spoon  in  such  a  way  that  the  handle  comes  edgewise  between 
the  gums.  By  this  procedure  the  child  will  always  open  his 
mouth,  and  if  his  head  is  well  fixed  then  a  few  seconds  will  be 
sufficient  to  inspect  his  throat. 

During  the  examination  of  the  mouth  diverse  inherited 
anomalies  may  be  met  with,  as,  for  instance,  complete  or  incom- 
plete adhesion  of  the  lips,  division  of  the  upper  lip — hare  lip 
(labium  leporinum)  or  of  the  soft  palate — cleft  palate  (palatum 
fissum). 

Some  symptoms  pertaining  to  the  mouth  may  have  signifi- 
cance in  the  diagnosis  of  other  diseases,  for  instance,  convulsive 
contraction  of  the  maxillse  is  usually  the  first  symptom  of  tetanus. 


46  EXAMTNATIOX    OF    CHILDREN 

A  constantly  open  mouth  often  occurs  in  scrofulous  children 
suffering  with  chronic  rhinitis  and  hypertrophy  of  the  tonsils.  In 
acute  cases  an  open  mouth  with  salivation  occurs  in  aphthous 
stomatitis ;  the  same  in  a  chronic  form  being  peculiar  to  idiotism. 

Thickening  of  the  upper  lip  belongs  to  the  signs  of  a  scrofu- 
lous habitus  and  develops  under  the  influence  of  repeated  snuffles 
with  caustic  secretion,  which  occasions  a  mild  inflammatory  pro- 
cess of  the  skin  and  the  subcutaneous  tissue  of  the  lip. 

The  mucous  membrane  of  the  lips  appears  as  a  favorable 
place  for  the  manifestations  of  hereditary  syphilis  in  the  form  of 
fissures  and  mucous  patches. 

(Diseases  of  the  Mouth  and  Throat  will  be  found  in  separate 
sections.) 

Inspecting  and  palpating  the  neck  may  occasionally  furnish 
many  data  for  the  diagnosis.  Attention  must  be  granted  to  the 
position  of  the  head  (see  Torticollis  and  Contracture  of  the 
Neck),  to  the  condition  of  the  spinal  column  (spondylitis),  of  the 
lymphatic  glands  and  of  the  cellular  tissue.  Regarding  the  im- 
portance of  circumscribed  (edema  of  the  neck  we  shall  speak 
tmder  the  Semeiology  of  the  Skin  and  that  of  the  Subcutaneous 
Cellular  Tissue.  But  besides  oedema  there  occur  on  the  neck  of- 
tener  than  elsewhere  diffuse  phlegmons  and  abscesses  of  the  lym- 
phatic glands.  The  phlegmons  most  often  accompany  malignant 
scarlatinal  sore  throat,  however,  suppuration  of  the  glands 
may  develop  either  independently,  especiall}  in  the  glands  behind 
the  ears,  or  because  of  some  wet  eruptions  on  the  head  (occipital 
glands  in  small  children)  or  on  the  face  (the  glands  under  the 
cliin).     About  micropolvadenitis  we  have  already  spoken   (page 

3B). 

As  an  inherited  anomaly  there  sometimes  occurs  on  the  neck 
a  fistulous  opening  or  small,  constantly  wet  hollow,  as  the  conse- 
quence of  incomplete  closure  of  the  branchial-archs.  The  open- 
ing is  locatecl  either  in  the  middle  line  of  the  neck  and  communi- 
cates through  a  narrow  canal  with  the  trachea  (fistula  colli 
trachealis  congenita),  or  on  the  sides,  above  the  sterno-clavicular 
articulation,  and  leads  to  the  oesophagus. 

Of  the  tumors  of  the  neck,  besides  those  which  depend  upon 
acute  swelling  of  the  glands  and  cellular  tissue,  there  is  developed 
in  new-born  children  a  small,  smooth,  solid,  oval  growth,  cov- 


EXAMINATION    OF    (11  i  LDKl'^.V 


47 


■ered  with  normal  skin  and  located  just  on  the  sterno-cleido-mas- 
toid  muscle.  This  tumor  develops  in  the  first  days  of  the  child's 
life,  indicating  rupture  of  this  muscle  during  labor  and  is  de- 
pendent upon  haemorrhage  at  the  place  of  rui)turc  and  upon  the 
formation  of  an  inflammatory  scar  (hccinafojiia  musciili  sterno- 
clcido-mastoidei).  This  tumor  is  always  unilateral  and  vanishes, 
without  leaving  any  traces,  in  two  or  three  weeks. 

[Theron  W.  Wilmer  lately  reported  three  cases  of  h?ematoma 
■of  the  sterno-cleido-mastoid  muscle.     The  mode  of  origin  of  the 


Fig.  3. — Characteristic  position  of  liead  in  hsematoma  of  the  sterno-mastoid 
muscle  (after  Kihner). 

tumor  is  described  by  the  author  in  the  following  manner : — "In 
breech  presentations  in  which  a  midwife  tries  to  disengage  the 
after-coming  head  by  pulling  with  great  force  upon  the  child's 
legs,  this  affection  is  almost  certain  to  follow  on  account  of  the 
laceration  of  the  mastoid  muscle.  The  expulsive  efforts  of  the 
uterus  alone  may  be  sufficient  to  cause  this  condition."  The 
hccmatoma  occurs,  according  to  the  same  author,  usually  at  or 


48 


EXAMINATION    OF    CHILDREN 


above  the  middle  of  the  muscle.  Wheii  the  injury  occurs,  the 
blood  escapes  from  the  torn  vessels  and  causes  a  soft  swelling  be- 
tween the  torn  fibers ;  the  tumor  gradually  becomes  harder  as  the 
clot  is  converted  into  fibrous  tissue.  The  skin  over  the  tumor  is 
freely  movable  and  of  normal  appearance.  The  size  of  the  tumor 
varies  from  that  of  a  small  hazelnut  to  that  of  a  walnut,  and 
sometimes  the  whole  length  of  the  muscle  is  involved. 

The  characteristic  position  in  which  the  infant  holds  its  head 
is  noticeable.  The  head  is  dra'icii  toicard  the  affected  side  by  the 
contraction  of  the  muscle,     (hig.  3-) 


Fig.   4. — Position   of   tumor    in   hematoma   of   the    sterno-mastoid   muscle 

(after  Kilmer). 


The  usual  duration  of  the  tumor  is  from  one  to  three  months. 
A  torticollis  may  persist  after  the  swelling  has  disappeared.  The 
situation  of  the  h?ematoma  in  the  substance  of  the  muscle  dift'er- 
entiates  it  from  the  swollen  lymph-nodes.     (Fig.  4.) 

The  anatomical  foundation  is  "laceration  of,  exudation  in,  and 
slight  inflammation  of  the  muscle  itself.""^ — Earle.] 

Of  chronic  neck  tumors  there  sometimes  develops  in  elder 
children  enlargement  of  the  thyroid  gland,  the  so-called  goitre — 
struma,  easily  recognisable  b}-  its  softness  and  location  on  the 
anterior  surface  of  the  neck.      In   our  locality    (Moscow)    this 


*Mcd.  Record.    February  27,  1904,  pp.  335-336. 


:x.\M[NAru)\   ()|-  (  II I  i.i)Ki:.\ 


49 


disease  seldom  occurs.  Comparatively  more  frequent  are  chronic 
tumors  of  the  lymphatic  ij;!aiids.  diffusing  in  big,  knobby  collec- 
tions. The  glands  appear  iri  such  cases  caseously  or  sarcomatous- 
ly    degenerated. 

Such  tumors  must  not  be  confounded  with  congenital  cysts 
of  the  neck — liygroma  cysticum  coiigenitiim  colli.  This  tumor 
consists  of  a  conglomeration  of  small  and  large  cysts,  as  deter- 
mined by  inspecting  and  palpating,  showing  the  presence  of  elastic 
and  fluctuating  elevations  of  spherical  form.  The  tumor  arises 
from  the  submaxillary  region,  being  always  congenital.  Its  size 
varies  from  that  of  a  walnut  to  that  of  the  fist  of  an  arlult  jier- 
son,  and  even  larger.  Sometimes  it  remains  /';/  .s-/(///^  quo:  how- 
ever, it  may  grow  remarkably  rapid  and  lead  to  suffocation.  The 
skin  which  covers  the  tumor  is  usually  unchanged,  or  thinned 
in  places,  but  in  some  cases  may  be  very  much  thickened,  i'unc- 
ture  gives  in  some  instances  a  fresh  or  slightl\ -turbid  Huid,  in 
others,  because  of  admi.xture  of  blood,  that  of  cliocolate-color. 

This  tumor  is  caused  by  hyperplasia  of  the  lymphatic  vessels 
and  may  be  called  lymj^hangioma  c}sticum  congenitum.  It  may 
be  mistaken  for  sarcoma  because  of  the  rapid  growth  and  solidity 
of  the  connective  tissue  stride,  which  serve  to  connect  separate 
cavities,  but  sarcomatous  elements  are  not  to  be  found  even  in 
tumors  with  a  very  rapid  growth.  The  development  sometimes 
stops,  but  spontaneous  healing  almost  never  results. 

In  examining  the  vertebral  column  one  should  give  attention 
to  its  form,  mobility,  painfulness  during  movement  or  pressure 
Uj^jon  the  head  and  upon  the  spinal  processes  as  well. 

The  examination  of  the  chest  in  children  is  performed  by 
the  same  methods  as  in  adults,  i.  e.,  by  inspection,  palpation, 
measuring,  percussion  and  auscultation.  Supposing  our  readers 
are  entirely  acquainted  with  all  these  methods  of  examination,  we 
need  onl}-  offer  brief  remarks  regarding  some  peculiarities  of 
percussion  and  auscultation  in  children,  because  some  trifles  are 
encountered  from  a  non-acquaintance  witli  which  the  physician 
may  be  led  into  entirely  false  conclusions.  Thus,  percussing  an 
asymmetrical  chest,  when  the  ribs  on  one  side  are  more  convex, 
the  other  one  being  flattened,  we  get,  ccvtens  paribus,  on  percus- 
sion of  the  convex  ribs  a  duller  sound  than  from  the  tiattened 
ribs.     The  chest  being  normall>-  developed,  a  mistake  ma.\-  be  ob- 


50 


EXAMINATION    OF    CHILDREN 


tained  because  of  the  child  sitting  improperly,  when,  for  instance, 
he  is  bent  over  to  one  side.  In  such  a  case,  likewise  in  lateral 
curvature  of  the  vertebral  column,  the  greater  dullness  will  be 
on  the  concave  side.  If  the  muscles  be  tense  on  one  side  of  the 
chest,  because  of  unequal  position  of  the  arms,  the  other  side 
relaxed,  then  dullness  will  be  obtained  on  the  side  of  the  con- 
tracted muscles  (provided  the  percussion  be  performed  over  the 
contracted  muscle). 

To  avoid  these  errors  one  must  liold  llic  child  in  such  a 
manner  that  his  shoulders  be  on  a  level  and  that  the  position 
of  the  shoulders  be  equal  on  both  sides,  if  we  deal  with  a  child 
one  or  two  years  old,  then  1  recommend  to  hold  him  firmly  during 
percussion  of  the  back.  To  this  end  the  child  is  seated  on  a 
horizontal  surface,  for  instance,  on  a  pillow  placed  on  the  table, 
the  arms  being  bent  at  a  rectangle,  the  ellx)ws  with  the  fore- 
arms on  the  abdomen  so  that  they  cross  each  other;  this  iX)sition 
is  maintained  by  the  right  arm  of  the  mother,  who  should  stand 
at  the  right  side  of  the  child.  The  left  arm  she  puts  on  the  oc- 
ciput of  the  child,  bending  the  head  forward  by  slight  pressure, 
in  order  to  prevent  it  being  thrown  backwards,  which  always 
happens  as  soon  as  the  percussion  of  the  l>ack  is  begun. 

Further,  one  should  bear  in  mind  that  the  percussion  sound 
becomes  considerably  dulled  if  the  examination  be  undertaken 
during  crying;  this  dullness  being  most  perceptible  in  the  inferio- 
posterior  portions  of  the  chest,  where  the  majority  of  expiratory 
muscles  are  attached.  Therefore,  if  the  child  is  crying  the  phy- 
sician should  percuss  one  place  by  short  and  frequent  strokes  until 
the  child  takes  a  deep  inspiration.  If  the  dull  resonance  be  ob- 
tained again,  then  it  is  quite  certainly  real. 

Percussion  should  always  be  performed  by  light  strokes,  as 
the  vibrations,  owing  to  the  great  elasticity  of  the  child's  chest 
and  its  small  dimensions,  are  too  easily  transferred  to  remote 
portions  of  the  lungs,  so  that  on  strong  percussion  the  dull  re- 
sonance of  a  circumscribed  area  may  be  entirely  deadened  by  the 
intense  resonance  of  the  healthy  surrounding  portions  of  the  lungs. 

In  percussing  the  back  beginners  often  make  a  mistake  by 
placing  the  pleximeter  too  low,  i.  e.,  where  there  is  no  lung  tissue. 
Regarding  the  position  of  the  lower  edge  of  the  lungs  one  may 
l^e  guided  by   certain   marks   of  the  skeleton.      The   question   is 


EXAMINATION    OF    CHIMmEN"  :;  I 

simplified  by  the  relation  of  the  lungs  to  the  skeleton  being  in 
both  small  children  and  adult  persons  constant,  namely:  on  the 
back  the  lower  margin  corresponds  to  the  spinal  process  of  the 
eleventh  vertebra  and  goes  from  this  point  forward,  intersecting, 
on  the  left  side,  on  the  linea  axillaris,  the  ninth  rib ;  and  on  the 
right,  the  1.  mamillaris,  the  sixth  rib. 

Auscultation  of  the  back  is  hindered  by  continuous  move- 
ments of  the  child  and  its  cry.  Because  of  restlessness  in  small 
children  auscultation  by  a  common  stethoscope  is  very  difficult, 
being  sometimes  altogether  impossible.  In  examining  the  back 
one  may  be  assisted  by  adopting  the  direct  metho<:l.  the  child  hav- 
ing been  jammed,  so  to  say,  between  the  head  and  the  hand  applied 
to  the  chest,  in  which  position  it  is  not  so  difficult  to  hold  him 
immovable.  But  before  applying  the  ear  to  the  child's  chest  one 
should  mark  the  place  to  be  examined,  and  then  listen.  Without 
this  precaution  the  beginner  often  makes  great  mistakes  by  auscul- 
tating, for  instance,  the  vertebral  column,  the  back  and  the  lum- 
bar region  instead  of  the  postero-lateral  surface  of  the  chest. 

It  is  inconvenient  to  directly  auscultate  the  anterior  surface 
of  the  chest,  especially  the  upper  portions,  because  of  lack  of 
.space.  It  is  better  to  use  for  such  purposes  a  soft,  elastic  stetho- 
scope, b\"  means  of  which  it  is  easy  to  watch  the  movements  of 
the  child,  and  by  the  aid  of  which  one  may  listen  with(iut  pro- 
ducing great  pressure  upon  the  skin  or  causing  any  pain.  But 
one  should  be  accustomed  to  such  a  stethoscope  in  order  to  ap- 
preciate the  sounds. 

With  regard  to  the  child's  crying,  this  is  an  obstacle  per- 
haps only  for  the  beginner,  while  an  experienced  physician  takes 
.advantage  of  the  time  of  the  cry  as  a  moment  favorable  for  the 
■examination,  first,  because  of  furnishing  a  possibility  of  examin- 
ing vocal  vibrations  (such  an  important  symptom  in  distinguish- 
ing pneumonia  from  pleurisy)  and  bronchophonia,  the  importance 
of  which  in  the  diagnosis  is  not  less  than  that  of  bronchial  respira- 
tion ;  secondly,  during  the  cry  the  patient  necessarily  takes  deep 
inspirations,  so  that  one  may  better  than  in  quiet  breathing  hear 
the  character  of  the  inspiratory  murmur  and  rales,  especially  min 
ute  and  crepitant  ones. 

On  auscultation  of  the  chest  of  a  crying  child  by  the  direct 
method  it  is  advisable,  according  to  Ziemssen,  to  stop  the  free 


52 


EXAMINATION    OF    CHILDREN 


ear  bv  the  finger,  in  order  to  concentrate  the  attention  on  the 
sounds  coming-  from  the  chest  to  the  auscuhating  ear. 

The  beginner  should  bear  in  mind  that  the  vesicular  respira- 
tory murmur  is  normally  expressed  very  sharply  after  the  second 
year  (therefore  it  receives  an  especial  name — puerile  resi)iration)and 
may  be  mistaken  for  bronchial  respiration.  In  children  under 
one  year  of  age  the  resjiiratory  murnnir  seems  to  be  diminished 
under  tlie  iniUience  of  feeble  muscular  activity. 

( )n  ins f^cc fillip  the  chest  we  have  to  regard  the  number  and 
character  of  the  respiratory  movements,  the  place  of  the  apex- 
beat,  the  shape  of  the  chest  and  the  condition  of  the  skin. 

The  resf^iratioii  in  iiew-bor>i  and  nurslings  is  of  the  abdomi- 
nal ty])e  and  becomes  gradually  costal  only  at  the  age  of  four 
years.  In  cliildrc'u,  during  the  first  months  of  life  the  respiration, 
in  the  normal  condition  during  com])lete  rest,  for  instance,  when 
the  child  slee])s,  is  not  entirely  regular,  because  shallow  insignifi- 
cant respirator)-  movements  alternate  with  deejier  ones,  ac- 
companied by  intervals.  Similar  irregularities  may  be  held  as 
pathological  only  in  children  after  the  second  year  of  life,  being 
of  especial  im])ortance  for  the  diagnosis  of  cerebral  diseases,  al- 
though occurring  also  during  ])ainful  respiration,  for  instance,  in 
rheumatism  of  the  muscles  of  the  chest  and  in  pleurisy. 

To  ordinary  occurrences  in  small  children  there  may  also  be 
referred  the  sinking  of  the  points  of  attachment  of  the  diaphragm 
on  the  lateral  and  anterior  walls  of  the  chest  (peripneumonic  fis- 
sure of  Trousseau),  easily  noticeable  also  during  quiet  breathing, 
but  especially  pronounced  during  the  cry.  In  a  child  over  four 
years  such  a  sinking  should  not  be  visible  during  quiet  breathing ; 
otherwise  we  have  right  to  suppose  one  of  two  things :  either  the 
access  of  air  to  the  lungs  is  hindered,  or  the  ribs  are  abnormally 
yielding,  soft.  If  the  obstacle  to  respiration  be  in  the  larynx  or 
trachea,  then  a  stenotic  respiratory  murmur  wall  obtain,  together 
with  deepening  of  the  supraclavicular  and  jugular  fossae.  If, 
however,  the  obstruction  be  in  the  bronchi,  the  respiration  neces- 
sarily becomes  considerably  accelerated,  and  the  child  coughs 
violently ;  in  the  absence,  however,  of  both  the  cough  and  symp- 
toms of  the  laryngeal  stenosis,  it  remains  only  to  suppose  softness 
of  the  ribs,  dependent  upon  rachitis. 

Politzer  refers  to  habitual,  continuous,  (from  the  moment  of 


EXAMIXATIOX    OF    CH  I  I.DRr-LX  53 

birth)  loud,  bleating  c.vpiratioii,  observed  suineiiuics  m  new-born 
during  the  first  days  of  life.  This  symptom,  depending  upon  ab- 
normal innervation,  and  disappearing  in  time  without  any  conse- 
quences, is  uneven,  divided  into  five  or  seven  intervals,  and  ac- 
companied by  a  loud  sound  like  the  bleating  of  a  goat;  while  in- 
spiration is  free,  hardl}'  audible,  short  and  in  general  normal. 
In  the  majority  of  cases  such  a  respiration  having  appeared  im- 
mediately after  birth  lasts  until  the  eighth  month  or  even  the  end 
of  the  year.  If  once  developed  it  does  not  stop  day  or  night. 
The  importance  of  this  symptom  consists  only  in  that  the  physi- 
cian being  acquainted  with  it  should  quiet  the  parents  and  not  re- 
sort to  unnecessary  measures. 

The  counting  of  the  respiratory  movements  is  performed 
either  by  the  eye,  or  by  the  hand  applied  to  the  epigastrium.  It  is 
impossible  to  define  exactly  the  number  of  respirations  in  small 
children,  as  it  varies  greatly  even  in  an  entirely  passive  state, 
judging  from  the  contradictory  testimonies  of  authors.  Vogel. 
for  instance,  gives  the  average  number  of  respirations  in  the  new- 
born as  26.4.  but  Ouetelet  says  44.  On  vertical  position  the 
new-born  breathes  one-third  quicker :  awakening  has  the  same 
effect  (46  to  58  times  a  minute).  At  an  average  the  number  of 
respirations  in  the  second  year  is  accepted  as  about  twenty-eight : 
in  the  third  and  fourth  years — twenty-five ;  from  six  up  to  ten 
years  it  is  twenty  to  twenty-eight.  The  frequency  of  respiration 
in  all  ages  increases  considerably  under  the  influence  of  fever  and 
forced  movements  (in  the  first  two  years  of  life,  the  temperature 
being  104  to  105  degrees  F.,  one  may  not  infrequently  count 
from  fift}-  to  seventy  respirations  in  a  mimite )  :  therefore  quick- 
ening of  the  respiration  does  not  prove  of  itself  the  presence  of 
pulmonary  disease.  It  is  in  favor  of  the  latter  only  when  the 
child  exhibits  at  the  same  time  other  symptoms  of  dyspnoea,  as, 
for  instance,  distention  of  the  al?e  nasi,  sinking  of  the  points  of 
attachment  of  the  diaphragm,  sighing  and  groaning  at  each  ex- 
piration. 

Attention  should  also  be  directed  to  the  ratio  of  the  number 
of  respirations  to  the  pulse.  If  the  former  bears  to  the  latter  a 
normal  ratio  of  i  13.5  or  4.5,  then  this  proves  the  cause  of  the 
accelerated  breathing  not  to  be  an  affection  of  the  lungs,  becaus: 
the  ratio  then  becomes   i  :2.5  to  2. 


54 


EXAMINATION    OF    CHILDREN 


Retarded  breathing  denotes  some  serious  disorder  of  the 
respiratory  nervous  mechanism.  It  occurs  in  cerebral  diseases 
which  produce  compression  of  the  brain,  in  uraemia  and 
cholera.     (*) 

In  acute  hydrocephalus  there  are  characteristic  deep  inspira- 
tions followed  by  long  intervals.  Such  inspirations  at  first  take 
place  from  time  to  time,  but  later,  in  the  stage  of  coma,  they  may 
be  observed  every  minute  in  the  form  of  Cheyne-Stokes  respira- 
tion. The  latter  consists  in  the  hardly  noticeable  breathing  be- 
coming with  each  inspiration  deeper  and  deeper,  reaching  the 
acme  and  then  again  decreasing  gradually  until  it  stops  for  about 
ten  to  thirty  seconds.  Cheyne-Stokcs  type  of  respiration  indi- 
cates exhaustion  of  the  respiratory  center,  being,  in  the  majority 
of  cases,  a  symptom  of  impending  death. 

That  this  symptom  is  not  to  be  hel<l  as  an  entirely  fatal 
one  was  proven  l)y  two  cases  with  a  favorable  termination  de- 
scribed by  me  in  the  year  1874  (Fratchcbni  Vcstuik).  Both  chil- 
dren were  about  one  year  of  age :  one  had  whooping-cough  com.- 
plicated  with  pneumonia  ;  the  other,  poisoning  from  opium. 

A  feeble  Cheyne-Stokes  breathing  in  new-born  and  in  very 
little  children  is  often  observed  during  sleep,  the  health  being 
perfect. 

The  complete  absence  of  respiratory  movements  in  a  newly- 
born  child  is  the  chief  symptom  of  imaginary  death,  or  asphyxia 
of  the  neii'-born.  Of  diagnostic  interest  only  is  the  definition  of 
the  stage  of  asphyxia,  because  u]X)n  the  decision  of  this  question 
depend  both  the  prognosis  (always  favorable  in  the  first  stage,, 
and  dangerous  in  the  second  one)  and  the  treatment. 

A  slight  degree  of  asphyxia  is  characterized  by  the  diminu- 
tion of  the  reflexes  and  of  the  muscular  tonus  ;  a  severe  one,  by 
the  disappearance  of  reflexes  and  complete  relaxation  of  the 
muscles.  In  the  former  case  the  pulse  is  comparatively  retarded, 
but  full,  the  integument  cyanotic,  the  face  pufl'y.  In  the  latter 
case  the  pulse  is  very  frequent  and  scarcely  palpable,  the  integu- 
ment being  pale.  Runge  gives  a  very  simple  and  practical  method 
of  defining  the  degree  of  asphyxia.     In  any  case  of  asphyxia  in 


*In  one  case  of  a  girl  about  eight  years  of  age  I  observed,  together 
with  Dr.  Gourvich.  retardation  of  breathing,  which  fell  to  four  per  minute, 
and  in  spite  of  that,  the  patient  recovered. 


EXA.MINA'UON    OF    rillIJ)Ki:x 


55 


the  new-born  the  physician  must  first  of  all  cleanse  the  mouth 
and  fauces  from  accunmlated  mucus  and  inspired  meconium.  For 
this  purpose  he  iutroduces  the  finger  mto  the  throat,  and,  if  this 
irritation  produces  in  the  child  any  reHex  evidence  (signs  of 
nausea  or  of  deglutition),  then  we  have  to  deal  with  the  first 
stage  of  asphyxia ;  per  contra,  with  the  second. 

In  elder  children,  coming  from  nervous  parents,  there  may 
sometimes  be  noted  an  entirely  peculiar  respiration,  to  which 
Politzer  called  attention  (*)  holding  this  type  as  a  positive 
symptom  of  chorea  major.  It  is  characterized  by  a  very  pro- 
longed (ten  to  fifteen  times  more  than  normal)  sonorous,  some- 
times even  as  if  grozding,  expiration,  the  inspiration  being  normal 
and  entire  absence  of  dyspnoea.  This  symptom  is  quite  sufficient 
for  the  diagnosis  of  chorea  major  if  only  repeated  typically,  i.  e., 
every  day  at  a  certain  time  or  during  the  whole  day,  but  with  cer- 
tain intervals,  for  instance,  every  seven  or  ten  seconds.  In  the 
latter  case  there  is  only  one  growling  respiration.  As  a  char- 
acteristic feature  of  this  malady  Politzer  holds  its  curability  by 
large  doses  of  c|uinine  (eight  to  sixteen  or  twenty-four  grains  a 
day),  as  well  as  that  this  symptom  may  last  alone  during  weeks 
and  even  months,  but  that  it  eventually  becomes  complicated  by 
other  disorders  in  the  motor  and  psychical  spheres. 

A  pronounced  costal  breathing  zvith  constant  groaning  in- 
spiration, but  without  stenotic  inspiratory  murmur  and  with  weak 
activity  of  the  diaphragm  (thus  without  drawing  in  of  the  in- 
ferior periphery  of  the  chest),  points,  according  to  Politzer,  to 
a  beginning  collapse  of  the  heart  and  depends  upon  the  insuffi- 
cient blood-supply  of  the  capillaries  of  the  pulmonary  vesicles. 
The  diagnostic  and  prognostic  meaning  of  this  symptom  is  ap- 
parent from  its  usually  appearing  earlier  than  other  symptoms 
of  heart  failure,  as  cyanosis,  pulsus  filiformis  and  rigidity  of  the 
extremities. 

With  regard  to  the  anomalies  of  the  shape  of  the  chest  we 
would  remark  that  bilateral  flattening  of  the  chest  with  the  ster- 
num being  protruded,  or  the  so-called  "pigeon-chest"  (increase 
of  the  antero-posterior  diameter,  the  transverse  being  simultan- 
eously decreased),  is  wrongly  held  by   some  as  a   symptom   of 

*Po''itzei-:  Jahrb.  flir  Kindcih..  XXI.  i<S84,  p.  5. 


56 


:\A.MI\.\T1()X    OF    CHir.nRRX 


undoubted  rachitis,  inasmucii  as  such  a  form  of  the  chest  mav 
arise  without  rachitis,  namel.w  in  the  case  of  chronic  hindrance  to 
the  air-supply  of  the  huigs  from  early  life,  as  occurs,  for  instance, 
in  chronic  hypcrlr()])hy  of  the  tonsils.     (  I-^i.^-.  5.) 


Fig.  5._-pigeoii-chest"  (Rehn). 

Unilateral  Haftcuiug  of  the  chest  occurs  in  pronounced  lateral 
curvature  of  the  vertebral  column  because  of  rachitis,  or  beca^ise 
of  retarded  absorption  of  an  abundant  pleuritic  exudation      On 


EXAMINATION    OF    CHILDREN  z^-j 

the  contrary  in  recent  cases  of  the  latter  there  is  noticed  luvilaieral 
enlargement  of  the  chest  with  flattening  of  the  intercostal  spaces. 
This  symptom  ma}-  occasionally  be  of  decided  importance  in  differ- 
ential diagnosis,  because  it  never  occurs  in  pneumonia,  even  when 
there  exists  extensive  pleuro-pneumonia.  In  the  latter  the  child, 
because  of  pain,  attempts  to  diminish  the  respiratory  excursions  of 
the  diseased  half  of  the  chest  by  means  of  bringing  the  ribs  near  to 
each  other,  so  that  the  corresponding  shoulder  lowers,  the  verte- 
bral column,  however,  somewhat  bends  (scoliosis)  with  the  con- 
vexity toward  the  opposite,  or  healthy,  side.  Similar  position  in 
the  case  of  dry  coughing  and  violent  fever  may  have  some  im- 
portance in  the  diagnosis  of  pleuro-pneumonia. 

A  circumscribed  protrusion  in  the  region  of  the  heart  is 
•observed  in  children  during  hypertrophy  of  the  heart  and  exuda- 
tive pericarditis. 

In  reference  to  the  soft  tissues  of  the  chest  attention  must 
be  paid  to  abscesses,  which  are  of  diverse  origin.  In  new-born 
children  they  most  often  occur  in  mastitis  neonatonnn  because 
of  milk-stagnation  in  the  mammary  glands,  which  act  during  the 
first  days  and  weeks  of  life  equally  in  both  boys  and  girls..  In 
•€lder  children  cold  abscesses  sometimes  occur,  covered  with  the 
normal  skin  and  painless  on  pressure.  They  require  an  entirely 
•dififerent  treatment,  which  depends  upon  their  arising  from  caries 
of  the  ribs  or  of  the  vertebral  colunm,  or  from  an  empyema  which 
is  going  to  open  spontaneously.  Their  diagnosis  is  not  difficult 
on  the  ground  of  concomitant  symptoms. 

Of  the  importance  of  the  dimensions  of  the  chest  in  an  esti- 
TTiation  of  the  general  development  of  the  organism  we  have  al- 
ready spoken. 

^fethods  of  examining  the  heart  in  childhood  do  not  exhibit 
any  difficulties,  but  in  estimating  results  one  should  bear  in  mind 
-some  physiological  deviations  from  the  normal  standard  of  adults. 
For  instance,  in  auscultating  the  heart  sounds  in  grown  persons 
it  is  easy  to  note  that  normally  the  accentuation  coincides  at  the 
apex-beat  with  the  first  sound,  but  in  the  regions  of  the  pulmonary 
.artery  and  aorta  with  the  second.  However,  in  small  children 
(under  two  years  of  age)  the  systolic  sound  is  stronger  all  over 
the  cardiac  region  than  the  diastolic  one.  being  the  loudest  at  the 
^pex-beat.     The  second  sound  is,  in  small  children,  loudest  in  the 


^8  EXAMINATION    OF    CHILDREN 

second  left  intercostal  space  (i.  e.,  in  the  area  of  the  pulmonary 
artery),  and  weakest  in  the  region  of  the  aorta.  This  may  be  ex- 
plained by  the  base  of  the  pulmonary  artery  lying  immediately 
behind  the  wall  of  the  chest,  near  the  place  of  application  of  the 
stethoscope,  while  the  aorta  lies  deeper,  its  base  being  partly 
covered  by  the  pulmonary  artery,  so  that  we  auscultate  the  sound 
of  its  valves  at  some  distance  from  the  place  of  origin. 

The  apex-beat  in  children  is  more  external  than  in  adults, 
and  is  the  more  displaced  the  younger  the  child,  so  that  in  children 
under  four  years  it  is  situated  to  the  left,  beyond  the  mammil- 
lary  line ;  from  four  up  to  seven  years  it  lies  most  often  on  the- 
mammillar}-  line,  and  from  seven  up  to  twelve  inwards  to  this- 
line  (Starck).  The  younger  the  child,  the  farther  the  apex-beat 
is  displaced  beyond  the  mammillary  line.  According  to  Starck,. 
in  children  under  three  years  this  displacement  reaches  one-and-a- 
half  to  two  centimeters  (one  inch)  ;  later  on,  not  more  than  one 
centimeter,  so  that  if  the  apex-lx.'at  lie  disjjlaced,  in  a  small  child, 
more  than  two  centimeters  beyond  the  mammillary  line,  or  in. 
one  older  more  than  one  centimeter,  tlieii  pathological  displace- 
ment of  the  apex-beat  may  be  suspected,  as  the  result  of  hyper- 
trophy or  dilatation  of  the  heart,  or  its  entire  dislocation.  With 
advancing  age  the  apex-beat  gradually  approaches  the  median 
line  and  sometimes  sinks  at  the  same  time,  so  that  in  small  children 
it  is  felt  usually  in  the  fourth  intercostal  space,  and  later  in  the 
fifth. 

If  the  apex-beat  in  a  small  child  be  most  pronounced  in  the 
epigastrium,  wath  the  heart-sounds  loudest  on  the  sternum,  yet 
with  the  absolute  dullness  of  the  heart  being  displaced  beyond  the 
right  end  of  the  sternum,  one  may  hold  that  the  heart  has  pre- 
served its  embryonal  position  on  the  median  line  (unless  it  is  dis- 
placed by  left  pleuritic  exudation).  If  the  heart  in  a  healthy 
child  be  displaced  still  more  toward  the  right  side,  the  apex-beat 
being  palpated  near  the  right  margin  of  the  sternum,  then  one 
must  look  for  situs  visccnini  inversus.  Displacement  also  of  the 
liver  and  the  spleen  should  be  noted. 

A  diffuse  and  strong  apex-beat,  the  region  of  cardiac  dull- 
ness being  at  the  same  time  normal,  the  sounds  pure  and  fever 
absent,  not  seldom  occurs  ii:"  elder  children  and  denotes  nervous 
palpitatior   of  the  hea.rt   (a  usual  symptom  of  chlorosis  and,  in 


EXAMINATION    OF    CHILDREN 


59 


general,  of  any  severe  anaemia).  In  small  children  similar  heart 
palpitations  may  depend  upon  inherited  cardiac  lesions,  not  all 
of  which  are  accompanied  by  a  murmur.  The  diagnosis  of  a  heart 
lesion  becomes  still  more  probable  if  the  child  easily  becomes 
cyanotic  under  the  influence  of  insignificant  causes  (slight  cough, 
cry). 

A  feeble  apex-beat  does  not  of  itself  prove  anything,  being 
sometimes  hardly  evident  even  in  healthy  children.  It  is  entirely 
dififerent  if  the  weakening  or  disappearance  of  the  apex-beat 
developes  during  some  disease.  Then  it  indicates  either  imminent 
heart   failure,  or  the   formation   of  a  pericardial  exudation.     If 


Fig.  6. — The  limits  of  cardiac  du'lness  in  a  child  one  year  of  age. 

enfeeblement  of  the  apex-beat,  the  sounds  being  clear,  de\'elops 
together  with  a  feeble,  frequent,  and  sometimes  irregular  pulse, 
during  any  not  very  severe  infectious  disease,  or  during  the  period 
of  convalescence,  in  short,  when  there  is  no  reason  of  supposing 
paralysis  of  the  heart  because  of  malignancy  of  the  toxins  of  the 
disease,  then  we  have  to  think  of  an  infectious  myocarditis.  Such 
myocardites  most  often  come  under  observation  in  diphtheria 
and  during  the  period  of  convalescence  from  scarlet  fever.  In 
the  further  course  of  such  myocardites  one  notes  in  from  three 
to  five  days  signs  of  dilatation  of  the  right  ventricle  (pulsation  in 
the  epigastrium  and  extension  of  the  dullness  of  the  heart  toward 
the  right  side  to  the  margin  of  the  sternum  and  farther)  and  con- 
gestive signs  (enlargement  of  the  liver,  small  quantity  of  urine). 


6o  EXAMINATION    OF    CHILDREN 

Regarding  the  results  of  percussing  the  heart  the  difference 
here,  in  comparison  with  adults,  consists  in  the  relative  cardiac 
dullness  being  increased  in  children.  The  younger  the  child  the 
higher  is  the  level  of  dullness  and  the  farther  it  spreads  over  the 
right  sternal  end. 

In  a  child  one  year  of  age  the  upper  margin  of  relative  cardiac 
dullness  begins,  according  to  Starck.  from  the  cartilage  of  the 
second  rib  (Fig.  6)  ;  in  a  six-year-old  child  from  the  second  inter- 
costal space  (Fig  7)  ;  and  in  a  twelve-year-old  from  the  third 
rib  (Fig.  8).  The  right  border  of  relative  dullness  of  the  heart 
reaches  in  a  one-year-old  child,  on  the  level  of  the  nipple,  the  right 


Fig.  7. — The  limits  of  cardiac  dulincss  in  a  cliild  six  years  of  age. 

parasternal  line ;  in  a  six-year-old  child  it  does  not  reach  it  en- 
tirely, and  in  a  twelve-year-old  in  the  middle  between  the  linea 
parasternalis  and  the  right  border  of  the  sternum.  The  left  border 
of  cardiac  dullness  in  all  ages  is  somewhat  displaced  beyond  the 
apex-beat. 

Absolute  dullness,  during  the  first  year  of  life,  begins  from 
the  lower  margin  of  the  third  rib ;  during  the  sixth  year,  from  the 
upper  edge  of  the  fourth  rib ;  and  the  twelfth  }ear  from  its  lower 
edge.  The  right  border  of  absolute  dullness,  in  all  ages,  reaches 
only  the  left  border  of  the  sternum ;  however,  the  left  one  does 
not  reach  the  mammillary  line.     (Figs.  6,  7  and  8.) 

A  diffuse,  dull  sound  of  the  heart,  the  apex-beat  being  sim- 
ultaneously increased,  denotes  hypertrophy  of  the  heart,  and  if 


EXAMINATION    OF    CHILDREN  6l 

the  apex-beat  be  weakened,  then  dilatation  of  the  heart  (weak 
pulse)  is  suspected,  or  accumulation  of  fluid  in  the  pericardial 
cavity,  hydropericardinni  (anasarca,  dropsy  of  the  abdomen)  or 
pericarditis  (friction  rub  of  the  pericardium,  some  painfulness 
on  pressure  upon  the  cardiac  region).  Hypertrophy  of  the  heart 
with  pure  sounds  suggests  in  the  patient  acute  or  chronic  nephri- 
tis (examination  of  the  urine).  If  the  hypertrophy  of  the  heart 
be  accompanied  also  by  roughness  of  the  accessible  arteries,  for 
instance,  of  the  brachial,  then  chronic  interstitial  nephritis  is  very 
probable,  although  it  is  of  very  rare  occurrence  in  children. 

Auscultating   the  heart   in   small   children     is     considerably 


Fig.  8. — The  limits  of  cardiac  didlness  in  a  child  twelve  years  of  age. 

hindered  by  its  small  size  and  by  the  very  frequent  contractions.  Both 
these  causes  often  make  difficult  the  determination  of  the  place  of 
the  murmur  and  the   time  of   its   formation. 

Dealing  with  a  munnur  in  the  cardiac  region  one  must  first 
of  all  decide  whether  it  arises  in  the  heart  itself,  in  the  pericard- 
ium, or  in  the  vessels.  In  the  former  case,  does  it  depend  upon 
an  organic  disease  of  the  heart,  i.  e.,  upon  lesion  of  the  valves, 
or  is  the  murmur  a  so-called  functional  or  anaemic  one  ? 

A  pericardiac  mimnur  may  be  recognized  in  the  majority 
of  cases  by  its  character,  being  either  scrawling  or  cracking  (in 
distinction  from  the  blowing  cardiac  murmur).  Further  one  may 
be  guided  by  the  pericardiac  friction  rub  increasing,  in  many 
cases,  from  the  pressure  by  the  stethoscope  or  from  changing  the 
recumbent  posture  for  the  sitting  one  (this  is.  however,  not  an 


62  EXAMINATION    OF    CHILDREN 

absolutely  certain  sign,  because  tbe  recumbent  posture  also  makes 
the  murmur  considerably  weak  during  valvular  diseases),  and 
again  by  the  murmur  bcinj^  heard  only  in  a  limited  area  and  by 
not  being  conducted  into  the  neck  vessels.  The  friction-rub  ap- 
pears most  often  at  the  base  of  the  heart,  for  instance,  on  the 
sternum  in  the  area  of  the  third  rib.  The  time  of  its  occurrence 
coincides  neither  with  the  systole,  nor  with  the  diastole.  Besides 
the  qualities  of  the  murmur,  pericarditis  is  characterized  by  two 
more  cardinal  symptoms,  namely  the  extent  of  the  cardiac  dull- 
ness and  the  peculiarities  of  the  apex-beat,  provided  we  deal  with 
a  fluid  pericarditis. 

The  more  fluid  accumulating  in  the  pericardial  cavity  the 
larger  will  be  the  heart-dullness,  which  appears  first  of  all  at 
the  base  of  the  heart,  reaches  on  the  left  side  approximately  to  the 
second  rib,  but  later  on  the  cardiac  dullness  increases  in  all  direc- 
tions. On  the  left  side  it  passes  beyond  the  mammillary  line, 
on  the  right  side  l)e\<)nd  the  sternal  end;  the  apex-beat  decreases 
considerably  (especiall}-  when  the  patient  is  lying  on  the  back; 
when  the  trunk  is  bent  forwards,  then  the  apex-beat  becomes 
more  visible)  and,  what  is  especially  important  in  the  diagnosis 
of  fluid  pericarditis  the  dull  sound  of  the  heart  passes  tozvard  the 
left  beyo)id  the  apex-beat.  This  is  absent  in  the  case  of  hyper- 
trophy and  dilatation  of  the  heart,  when  the  external  boundary  of 
the  cardiac  dullness  coincides  with  the  apex-beat. 

During  pericardial  exudation  in  children  there  appears  much 
earlier  than  in  adults  a  marked  protrusion  of  the  region  of  the 
heart,  at  once  showing  the  physician  wdiat  he  is  dealing  with. 

Anceniic  murniurs  dififer  from  organic  ones  especially  by  the 
simultaneous  absence  of  any  other  symptoms  of  heart  aflFection,  i. 
€.,  the  dull  sound  remains  in  normal  limits  and  the  second  sound 
of  the  pulmonary  artery  is  not  accentuated.  These  murmurs  al- 
ways coincide  with  the  systole  (never  with  the  diastole)  being 
most  often  heard  at  the  base  of  the  heart,  in  the  area  of  the  pul- 
monary artery  (almost  never  in  the  aorta),  i.  e.,  on  the  left  side  of 
the  sternum  in  the  second  intercostal  space  and  on  the  sternum 
itself.  Further  it  is  also  characteristic  that  anaemic  murmurs  are 
never  very  loud.  On  the  contrary  they  are  distinguished  by  the 
soft,  blonnng  character  and  are  never  noted  by  the  hand  applied 
to  the  region  of  the  heart.     Thev  are  met  with  onlv  in  anaemic 


EXAMIXATiOX     OF    C  1 1  I  LI  )Ki:X  63 

■and  emaciated  or  febrile  patients,  beiui;-  usually  accompanie<l  bv 
venous  murmurs  below  the  claz'iclcs. 

Anaemic  cardiac  nuuMiiurs,  altlioui^ii  seldom,  occur  also  in 
children  under  three  years  of  age,  and  in  this  our  observations 
dilTer  from  those  of  Hochsinger  ('■')  whose  studies  cover  ninety- 
four  cases  of  decidedl}'  expressed  anaemia.  In  children  under 
four  years  of  age  he  never  met  the  anaemic  murmur,  in  the  fifth 
year  in  five  per  cent.,  in  the  sixth  in  twenty^five  per  cent,  and  in 
the   seventh,   forty  per  cent. 

Accidental  nnirmurs  very  seldom  occur  in  small  children, 
thus  considerably  increasing  the  diagnostic  importance  of  cardiac 
murmurs  by  permitting  the  great  probability  of  an  organic  lesion 
•of  the  heart  on  the  ground  of  the  systolic  murmur  only,  wherever 
it  may  arise,  even  in  case  this  murmur  was  not  accompanied  by 
■the  accentuated  second  pulmonary  sound,  or  by  increased  cardiac 
dullness,  which  not  very  seldom  occurs,  for  instance,  in  recent 
-cases  of  endocarditis,  as  well  as  in  congenital  heart  diseases. 

According  to  Hochsinger  accidental  murmurs  are  heard 
■mostly  in  the  area  of  the  pulmonary  artery  (or  exclusively  here)  ; 
never  extend  over  the  whole  cardiac  region  (for  instance,  over  the 
aorta)  and  the  back,  and  never  obscure  the  first  sound.  The  mur- 
inur  decreases  with  improvement  of  the  ansemia. 

Organic  murmurs  of  the  heart  may  be  mistaken  sometimes 
for  a  very  pronounced  venous  murmur,  which  is  heard  in  healthy 
persons  only  on  the  neck,  near  the  posterior  margin  of  the  sterno- 
cleido-mastoid  muscle  near  its  attachment  to  the  clavicle.  It  may 
be  heard  in  anaemic  persons  on  both  sides  of  the  chest  even  below 
the  clavicles,  down  to  the  second  or  third  rib  (in  vena  anonyma), 
so  that  it  may  be  mistaken  for  a  cardiac  murmur.  A  mistake  here 
is  the  more  possible  in  that  the  venous  murmur  increases  under 
the  influence  of  all  conditions  accelerating  the  blood  current  in 
the  neck-veins,  thus  also  during  the  diastole.  Therefore  it  may 
-simulate  a  diastolic  murmur  in  the  aorta  or  pulmonary  artery, 
leading  thus  to  the  diagnosis  of  a  non-existing  semilunar  insuffi- 
ciency. 

Venous  murmurs  below  the  clavicles  occur  in  small  children 
under  two  years  of  age,  as  well  as  in  older  ones,  but  oftener  in 


*Hochsinger:  Die  Auscultation  des  Kindlichen  Hersens.    1890  Wien. 


64  EXAMINATION    OF    CHILDREN 

the  former.  They  differ  from  cardiac  murmurs,  first,  by  their 
constant  character  (the  venous  murmur  is  rarely  intermitting,, 
even  if  it  increases  during  the  diastole  it  does  not  disappear  en- 
tirely during  the  systole)  ;  second,  their  intensity  changes  con- 
siderably, depending  on  the  turning  of  the  head ;  the  murmur 
increases  on  turning  the  face  toward  either  side,  decreasing  or 
even  disappearing  altogether  during  the  straight  position  of  the 
head,  or  it  is  still  stronger  in  the  last  case.  The  main  thing  here 
is  that  the  strciii^th  of  the  mnnnur  chaiii^cs.  depending!;  upon  the 
position  of  the  head.  A  slight  ])ressure  u])on  the  vein  by  the 
stethoscope  or  finger  increases  the  murmur,  but  com])lcte  com- 
pression does  not  cause  it  to  disappear. 

If  the  venous  murmur  be  heard  only  on  the  neck,  and  still 
better  when  the  face  is  turned  toward  one  side,  then  it  is  of  na 
diagnostic  importance.  However,  if  it  is  noted  below  the  clavicles,, 
or  on  the  sterno-clavicular  articulation,  then  it  always  points 
toward  anaemia.  If  an  anaemic  venous  murmur  be  heard  below 
the  clavicles,  then  it  always  may  be  heard  also  behind  the  ear, 
over  the  mastoid  process  (murmur  of  the  sinus)  and  sometimes 
also  on  the  nape  of  the  neck,  immediately  below  the  margin  of 
the  hair.  In  small  children,  with  an  open  fontanelle,  the  anaemic 
murmur  is  also  heard  on  the  anterior  fontanelle.  In  our  opinion 
the  so-called  "fontanelle  murmur"  is  nothing  but  an  anaemic  one 
of  the  cerebral  sinuses,  because  it  is  especially  loud  in  a  pro- 
nounced anaemia,  being  usually  accompanied  by  a  murmur  at 
the  mastoid  processes  and  below  the  clavicles.  In  slight  degree? 
of  anaemia  the  murmur  at  the  mastoid  process  usually  appears- 
earlier  than  the  subclavicular  murmur.  In  grave  cases  of  anaemia 
venous  murmurs  are  to  be  heard  also  on  the  back,  especially  along 
the  vertebral  column  in  its  upper  costal  portion. 

The  meaning  of  organic  murmurs  in  children  is  the  same 
as  in  adults ;  therefore,  in  the  diagnosis  of  heart  diseases  atten- 
tion is  to  be  given  to  the  point  of  origin  of  the  murmur  (i.  e.,. 
where  it  is  best  heard)  and  to  the  signs  of  hypertrophy  of  the 
heart.  But  in  examining  one  should  bear  in  mind  that  congenital 
cardiac  lesions  occur  in  small  children  oftener  than  in  adults 
and  are  difficult  to  be  diagnosticated  not  only  on  account  of  the 
above-mentioned  conditions  (frequency  of  the  pulse,  small  dimen- 
sions of  the  heart),  but  because  they  are  comparatively  seldon> 


EXAMINATION    OF    CHILDREN 


^5 


pure,  being  almost  always  combined,  i.  e.,  a  lesion  of  one  valve 
leads  to  affection  of  anotber  one,  for  instance,  congenital  narrow- 
ing- of  tbe  pulmonary  artery  is  almost  always  combined  witb 
patency  of  the  ductus  arteriosus,  or  with  insufficient  development 
of  the  interventricular  septum ;  stenosis  of  the  tricuspid — with 
patency  of  the  oval  opening,  etc.,  so  that  murmurs  may  arise  In 
several  places.  As  a  peculiarity  of  congenital  heart  lesions  one 
may  also  point  out  that  they  are  referred  especially  to  the  right 
heart  (pulmonary  artery)  and  that  such  patients  are  verv  prone 
to  cyanosis  (become  cyanotic  when  crying)  and  are  characterized 
by  muscular  weakness  and  general  malnutrition. 

The  following  cardiac  defects  bear  an  especial  relation  to 
childhood,  being  mostl}-  congenital. 

(i)    Stenosis  of  the  pulmonary  artery. 

(2)  Patency  of  the  ductus  Botalli. 

(3)  Insufficiency  of  the  semilunar  valves  of  the  pulmonarv 
artery. 

(4)  Stenosis  of  the  tricuspid  valve. 

(5)  Insufficiency  of  the  tricuspid  valve. 

(6)  Defect  of  development  of  the  interventricular  septum. 

(7)  Patency  of  the  foramen  ovale. 

If  any  of  these  defects  exist  definitely,  then  it  may  be  recog- 
nized by  the  following  symptoms:  Stenosis  of  the  pulmonary  ar- 
tery, like  patency  of  the  ductus  arteriosus  (d.  Botalli),  manifests 
itself  by  a  systolic  murmur  in  the  area  of  the  pulmonary  artery 
(the  second  left  intercostal  space)  and  by  hypertrophy  with  dila- 
tation of  the  right  ventricle  (increase  of  the  cardiac  dullness  to- 
ward the  right  side,  pulsation  in  the  epigastrium).  The  differ- 
ence is  that  in  patency  of  the  ductus  arteriosus  the  pulmonary 
artery  is  overfilled  w-ith  blood  and  therefore  the  second  sound 
is  considerably  accentuated ;  while  in  narrowing  of  the  pulmonary 
artery  the  second  sound  is  also  accentuated,  but  the  cyanosis  is 
here  more  pronounced  than  in  the  former.  For  the  diagnosis  of 
pure  stenosis  of  the  pulmonar}-  artery  a  murmur  alone  is  in- 
sufficient ;  one  nnist  yet  prove  the  presence  of  dilatation  of  the 
right  ventricle.  In  acquired  stenosis  of  the  pulmonary  arter\- 
a  murmur  in  the  carotid  arteries  is  never  present,  which  circum- 
stance may  serve  in  doubtful  cases  for  the  differentiation  of 
stenosis  of  the  pulmonary  artery  from  aortic  stenosis.     However. 


66  EXAMINATION    OF    CHILDREN 

in  congenital  defects  this  s}mptom  is  not  of  decided  value,  as  the 
systolic  murmur  in  the  carotid  arteries  may  also  accompany  pul- 
monary stenosis,  when  there  exists  simultaneously  an  opening  in 
the  interventricular  septum  (often  a  complication  of  pulmonary 
stenosis)  or  a  patency  of  the  ductus  arteriosus.  The  latter  being 
open  the  murmur  on  the  back  (between  the  left  scapula  and  the 
vertebral  column)  is,  on  auscultation,  often  louder  than  over  the 
chest ;  it  increases  during  inspiration  (  because  of  the  strong  blood- 
current  from  the  aorta  produced  by  the  sucking  activity  of  the 
lungs)  and  decreases  during  expiration  ;  cyanosis  being  absent. 
In  stenosis  of  the  pulmonary  artery  the  murmur  also  spreads  on 
the  back,  but  remains  always  weaker  than  on  the  front  of  the 
chest.  It  is  best  heard  on  a  line  connecting  the  second  inter- 
costal space — at  the  sternal  end — with  the  inner  third  of  the 
clavicle.  (The  murmur  decreases  rapidl\-  in  all  other  places  and 
especially  in  a  direction  towards  the  right ) . 

As  general  symptoms  of  stenosis  and  insuificiency  of  the  tri- 
cuspid valve  there  will  be :  Increase  of  the  cardiac  dullness  toward 
the  right,  because  of  hypertrophy  and  dilatation  of  the  right  heart 
(especially  of  the  auricle)  ;  a  marked  venous  stasis,  manifested 
by  cyanosis,  dropsy  and  venous  pulse ;  desolation  of  the  pulmonary 
artery,  so  that  its  second  sound  is  not  accentuated.  These  symp- 
toms are  the  same  as  occur  in  narrowing  of  the  pulmonary  artery, 
but  the  difference  lies  in  the  position  of  the  loudest  murmur; 
in  lesions  of  the  tricuspid  valve  it  is  near  the  right  end  of  the 
sternum  in  the  area  of  the  fourth  or  fifth  intercostal  space,  being" 
diastolic  in  stenosis,  and  systolic  in  insufficiency. 

In  defects  of  the  interventricular  septum  the  blood  passes 
during  the  systole  partly  from  the  left  ventricle  into  the  right 
one,  which  becomes  therefore  hypertrophied.  The  second  pul- 
monic sound,  because  of  increased  arterial  pressure,  becomes  ac- 
centuated ;  in  the  middle  of  the  sternum  or  at  the  place  of  the 
apex-beat  there  is  heard  a  systolic  murmur.  These  symptoms  are 
quite  the  same  in  insufficiency  of  the  bicuspid  valve,  so  that  an 
exact  diagnosis  is  seldom  possible,  especially  in  those  cases  where 
the  systolic  murmur  is  decidedly  audible  over  the  sternum  in  the 
area  of  the  third  intercostal  space,  the  sounds  being  clear  at  all 
openings.  According  to  Kissel  an  opening  in  the  interventricular 
septum  may  be  diagnosticated  when  a  congenital  narrowing  of  the 


EXAMINATION    OF    CHILDREN  ( ,- 

pulnionary  artery  in  an  elder  child  is  accompanied  neither  by  a 
marked  dilatation  of  the  right  heart  (especially  of  the  auricle),  by 
dilatation  of  the  neck-veins,  nor  by  symptoms  of  labored  and 
increased  heart  activity,  while  the  cyanosis  is  at  the  time  very  well 
developed  and  changes  but  little  in  its  degree.  (*)  The  communi- 
cation between  the  ventricles  is  usually  not  accompaned  by  cya- 
nosis. Hypertrophy  of  the  heart  is  not  necessary  even  in  cases 
of  a  very  strong  murmur  which  is  felt  under  the  hand  as  a 
"cat's  purr."  Absence  of  cyanosis  and  of  hypertrophy  of  the 
heart  is  in  the  presence  'of  such  a  murmur  characteristic  of  the 
existence  of  an  opening  in  the  interventricular  septiun. 

Patency  of  the  oval  opening  does  not  manifest  itself  in  many 
cases  by  any  objective  signs.  If  it  be  impossible,  as  often  happens, 
to  find  out  at  what  point  the  murmur  arises,  and  its  coincidencies, 
while  the  hvpertrophy  of  the  heart  is  at  the  same  time  distinctly 
developed,  as  well  as  cyanosis  or  some  inclination  to  the  latter, 
then  the  diagnosis  is  only  that  of  some  congenital  anomaly  of  the 
heart. 

When  dealing  with  cardiac  murmurs  in  a  child,  it  is  not 
always  easy  to  decide  whether  they  depend  upon  an  inherited  or 
an  acquired  defect  of  the  heart.  In  deciding  such  a  question  the 
history  is  of  great  value.  In  favor  of  an  inherited  defect  the 
following  facts  are  important : 

(i)  The  child  has  manifested  some  disposition  toward  cya- 
nosis from  the  first  months  of  life,  to  become  cyanotic  during 
crying  or  coughing. 

(2)  The  parents  have  noticed  the  increased  heart  activity. 

(3)  Heart-murmurs  were  perhaps  found  by  the  physician 
during  the  first  months  of  life. 

(4)  The  child  was  born  in  a  state  of  asphyxiation  (this 
circumstance  plays  a  role  in  the  aetiology  of  patency  of  the  ductus 
arteriosus). 

(5)  The  child  suffers  neither  from  rheumatism,  nor  from 
any  other  acute  infectious  disease  which  creates  a  disposition  to 
heart  lesions,  (although  an  idiopathic  endocarditis  sometimes 
occurs  in  childhood,  but  it  always  ends  with  convalescence  in  from 
two  to  four  or  eight  weeks). 


*"rratch"  1892.  No.  2. 


68  EXAMTX.\TIO>T    OF    CHILDREX 

In  the  case  of  an  incomplete  anamnesis,  which  does  not  dis- 
pel the  donbt,  the  following  circumstances  may  be  of  significance 
in  the  diagnosis : 

(t)  Age  under  three  years.  Acquired  heart  diseases  occur 
in  small  children  very  seldom ;  accidental  and  anaemia  murmurs 
still  more  rarel}'.  Therefore,  a  cardiac  murmur  in  a  small  child 
mav  by  itself  prove  the  existence  of  an  inherited  disease  of  the 
heart,  especially  if  the  murmur  be  loud  and  spreading,  since 
acquired  cardiac  diseases  are  at  this  age  almost  exclusively  in 
the  form  of  a  mild  mitral  insufficiency,  manifested  by  a  soft  blow- 
ing murmur. 

(2)  An  inherited  heart  disease  may  be  suspected  with  great 
certainty  in  all  cases  in  wliich  we  have  to  deal  with  a  diffuse, 
loud  murmur  spread  all  over  the  cardiac  region,  while  its  punctum 
maximum  is  not  well  expressed.  This  is  frequently  met  with  in 
combined  heart  diseases  which  are  almost  always  congenital.  On 
the  contrary,  in  acquired  diseases  the  punctum  maximum  is  usual- 
ly easily  determined. 

(3)  Inherited  cardiac  defects  are.  in  the  majt)rity  of  cases, 
characteristic  in  giving  rise  to  the  appearance  of  systolic  murmur 

(stenosis  of  the  pulmonary  artery  or  of  the  ascending  portion 
of  the  aorta ;  patency  of  the  ductus  arteriosus ;  opening  in  the 
interventricular  septum,  insufficiency  of  the  mitral  or  tricuspid 
valves  because  of  congenital  endocarditis,  as  well  as  a  combina- 
tion of  some  of  these  lesions).  For  this  reason  pure  diastolic 
nuirnuu"s  hardly  ever  occur  in  congenital  heart  defects.  They 
are  seldom  met  with  even  when  combined  with  the  systolic  mur- 
mur, and  this  occurs  comparatively  oftener  in  elder  children  be- 
cause of  complication  with  endocarditis  of  the  cusps).  It  follows 
that  a  pure  diastolic  murmur  almost  excludes  congenital  lesion  of 
the  heart. 

(4)  The  cyanosis  of  the  skin  and  of  the  mucous  membranes, 
or  some  disposition  to  cyanosis  (its  appearance  at  each  cry,  cough, 
etc.),  in  the  absence  of  any  other  apparent  signs  of  disturbance 
of  circulation,  is  met  with  only  in  the  inherited  heart  diseases. 
If  cyanosis  be  noted  in  a  child  from  the  first  days  of  life  then 
the  diagnosis   of   congenital   heart   disease   may   be   made   posi- 


KXAMIXAIION    OK    CUll.DKKN  (nj 

tively,  even  in  the  absence  of  murninrs  and  enlargement  of  cardiac 
dullness.     (*) 

In  the  presence  of  a  cardiac  mnrninr  any  deforniitv  or  mal- 
development  (labium  leporinum,  palatum  fissum.  i)olydactilia, 
epispadia,  etc.,)  may  be  in  favor  of  an  inherited  defect.  Of  the 
same  value  is  retarded  physical  and  mental  development,  gen- 
eral debility  of  the  organism  and  pronounced  pallor  from  the  first 
year  of  life. 

To  these  data  one  luay  add  the  following,  drawn  1)\  lloch- 
singer  from  his  observations:  (**) 

(1)  rcry  loud  cardiac  niiinnurs,  the  dullness  of  the  heart 
beiii^  normal  or  slii^htly  increased,  occur  in  childhood  only  during 
congenital  heart  diseases.  If.  however,  loud  murnuirs  signify 
an  acquired  heart  lesion,  then  the_\  are  alnwst  always  accompanied 
by  considerable  enlargement  of  the  heart  dullness. 

(2)  Cardiac  uuu-nuu-s,  in  the  presence  of  increased  cardiac 
dullness,  the  apex-beat  being  feeble,  in  small  children  points  toward 
some  congenital  defect,  because  the  spreading  of  the  dullness  de- 
notes in  such  cases  hypertrophy  of  the  right  heart,  the  left  being 
altered  but  little.  However,  in  acquired  endocarditis  of  children 
the  left  heart  becomes  particularly  afifected,  so  that  the  apex-beat 
will  be  increased. 

(3)  Complete  absence  of  murmurs  in  the  area  of  the  apex- 
beat,  while  they  are  distinctly  audible  on  the  sternum  and  in,  the 
area  of  the  piilnu^iiary  artery,  speaks  for  the  defect  of  the  inter- 
ventricular sept II in  or  narrowing  of  the  pulmonary  artery,  rather 
than  for  endocarditis. 

14)  An  abnormally  feeble  second  pulmonic  sound  in  the 
presence  of  a  distinctly  developed  systolic  nuu'mur  in  earl\-  child- 
hood may  be  explained  only  by  inherited  stenosis  of  the  pulmonary 
artery:  therefore,  this  symptom  has  great  diagnostic  value. 

(5)  Absence  of  noticeable  thrill,  despite  irry  loud  murmurs 
all  over  the  pericardial  area  occurs  almost  wholly  in  inherited 
defects  of  the  septum,  and  speaks  thus  against  an  acquired  heart 
disease. 

(6)  Loud  sysfolic  murmurs  with  the  pnnctum  maximum  in 
the  upper  portion  of  the  sternum,  and  without  considerable  hyper- 

*Kissel  :  I'ratch.  t.   11,  IcSqj,  p.  55,  No.  2. 
**  /.  c.  p.   145. 


yO  EXAMINATION    OF    CHILDREN 

trophy  of  the  left  ventricle,  are  very  important  in  the  diagnosis  of 
patency  of  the  ductus  Botalli,  and  cannot  be  explained  by  endo- 
carditis of  the  aortic  valves. 

Hochsinger  also  ascribes  great  significance  to  the  accentua- 
tion of  the  second  sound.  The  main  thing  is  that  the  second  sound 
at  the  base  of  the  heart  is,  contrary  to  that  in  adults,  normally 
never  accentuated,  so  that,  if  the  second  sound  of  the  pulmonary 
artery  prevails,  this  undoubtedly  proves  the  considerable  in- 
crease of  pressure  in  the  small  blood  circle.  If  the  second  sound 
be  noted  in  a  cyanotic  new-born,  or  in  a  nursling,  then  the  diag- 
nosis is  in  many  cases  much  easier,  as,  for  instance,  in  the  follow- 
ing conditions : 

(i)  Loud  murmurs  on  the  manubrium,  as  well  as  cyanosis 
and  accentuated  second  sound,  are  in  favor  of  a  zcide  opening  of 
the  ductus  arteriosus. 

(2)  Clear  sounds  with  very  considerable  cyanosis  and  an 
increased  second  sound  are  pathognomonic  signs  of  inherited 
transposition  of  the  pulmonary  artery  and  aorta  (generally  speak- 
ing, the  accentuated  second  sound  shows  that  the  pulmonary 
artery  has.  in  such  a  case,  its  origin  from  the  left  ventricle). 

(3)  The  cardiac  murmurs  which  are  not  to  be  referred  to  the 
openings  of  the  heart  (for  instance,  on  the  sternum  in  the  area 
of  the  third  rib),  cyanosis  and  decidedly  accentuated  second  sound 
signify  with  great  probability  in  favor  of  combination  of  the 
transposition  of  the  vessels  with  the  simultaneous  patency  of  the 
foramen  in  the  interventricular  septum. 

The  frequency  of  the  pulse  in  children  is  liable  to  still  greater 
variations  than  the  respiration.  The  cry  and  restlessness  of  the 
child  quicken  the  pulse  to  such  an  extent  that  its  counting  at  the 
time  cannot  give  a  satisfactory  result.  In  small  children  only  is 
the  counting  of  the  pulse  during  sleep  of  some  importance. 

Pulse  counting  is  determined  by  the  finger,  the  radial  artery 
being  slightly  compressed.  During  febrile  conditions  and  in  gen- 
eral during  any  considerable  quickening  of  the  pulse,  when  the 
latter  reaches,  for  instance,  about  160  or  more,  one  must  count 
two  pulse  beats  for  one,  in  order  not  to  lose  the  number.  By 
such  a  method  we  may  correctly  count  even  200  beats  per  minute, 
while  by  the  ordinary  method  of  counting  one  cannot  correctly 
note  even  160  pulsations. 


EXAMIXATIOX    OF    CHILDREN  y\ 

111  examining:  the  pulse  attention  must  be  directed  especially 
to  its  frequency,  rhythm  and  fullness. 

From  120  to  140  beats  per  minute  is  regarded  normal  fre- 
quency during  the  first  half  year ;  in  the  second  half,  from  100 
to  130;  during  the  second  year,  90  to  120;  from  three  up  to  five 
years,  70  to  100;  from  six  to  seven  years,  70  to  100.  Crying 
and  fever  both  accelerate  the  pulse  rate  20  to  50  beats  per  min- 
ute. 

A  retarded  and  irregular  pulse  occurs  most  often  in  cerebral 
■diseases,  occurring  with  symptoms  of  brain  compression,  as  well 
as  in  all  kinds  of  jaundice  (in  elder  children),  in  gastritis,  during 
the  period  of  convalescence  after  acute  febrile  diseases,  under  the 
influence  of  some  drugs  (digitalis,  opium),  and  in  some  children 
€ven  in  a  normal  condition.  The  younger  the  child,  the  weaker  is 
the  prohibitory  nervous  apparatus  in  general,  and  the  vagus  espe- 
cially, therefore  the  more  rarely  is  a  retarded  pulse  met  with.  In 
children  during  the  first  or  second  year  of  life  it  is  seldom  pos- 
sible to  note  a  characteristic  cerebral  pulse  even  dtiring  acute 
hydrocephalus.  At  this  age  an  important  diagnostic  sign  is  a 
relative  retardation,  for  instance,  112  pulse  beats,  the  temperature 
being  38  degrees  C.  (100.4  degrees  F.),  while  in  elder  chiUlren 
the  pulse  rate  falls,  under  the  same  conditions,  to  70  and  even  to  60 
beats  per  minute. 

A  feeble  pulse,  being  at  the  same  time  frequent,  denotes 
heart-failure.  About  the  degree  of  danger  attending  this  symptom 
we  judge  from  the  accompanying  signs  on  the  part  of  other 
organs.  As  bad  omens  there  may  be  mentioned  frigidness  of  the 
extremities;  symptoms  of  dilatation  of  the  right  heart  (dilatatio 
cordis),  manifested  by  an  extension  of  the  dull  sound  beyond  the 
right  end  of  the  sternum,  the  apex-beat  being  feeble ;  the  liver 
congested  because  of  venous  stagnation ;  and  cyanosis. 

Heart  failure  in  its  acute  form  occurs  most  often  in  grave 
cases  of  acute  febrile  diseases,  especially  in  scarlet  fever,  but  in 
some  cases  paralysis  of  the  heart  appears  in  patients  even  in  the 
absence  of  any  elevation  of  temperature,  because  of  the  influence 
of  various  toxins.  Such  an  acute  paralysis  of  the  heart  most 
often  occurs  during  dysentery  and  especially  during  diphtheria. 
In  the  latter  case  the  heart  failure  becomes  especially  important 


72  EXAMINATION    OV    CHILDREN 

because  it  occurs  in  the  period  of  convalescence,  when  the  patient 
seems  to  be  out  of  an}-  danger. 

The  frequency  of  heart  paralysis  depends  upon  the  character 
of  the  epidemic.  Many  think  that  death  from  diphtheritic  paralysis 
sets  in  suddenly,  but  this  is  not  true,  as  careful  examination  of  the 
patient  always  indicates  many  hours,  or  even  several  days,  in  ad- 
vance diverse  precursors  of  the  imminent  catastrophe. 

Paralysis  of  the  heart  after  diphtheria  affects  boys  oftener 
than  girls  (2:1)  ;  and  weak,  emaciated  children  oftener  than  those 
with  a  good  nutrition. 

Heart  failure  must  be  feared  when,  despite  the  resolution 
of  the  local  morbid  process  in  the  fauces,  the  general  condition 
of  the  patient  does  not  improve ;  the  child  does  not  care  for  eat- 
ing ;  remains  languid  and  apathetic ;  sleeps  poorly  during  the 
night ;  and  when  ])aralysis  of  the  soft  palate  appears.  In  the  fur- 
ther course  undoubted  symptoms  of  cardiac  weakness  appear,  as 
feeble,  quickened  or  (this  is  still  more  important)  retarded  and 
irrcij^iilar  pulse.  In  severer  cases  extension  of  the  cardiac  dull- 
ness toward  the  right  side  takes  place,  swelling  of  the  liver,  and 
diminutiiMi  of  the  quantity  of  urine ;  the  patient  is  either  somno- 
lent and  apathetic,  or  excited,  constantly  changing  his  posture  as  if 
from  cardiac  anxiety  (anxietas  cordialis).  Auscultating  the  heart 
the  sounds  are  found  very  feeble,  sometimes  at  the  apex  an  in- 
significant nuirmur  is  audible :  the  second  pulmonary  sound  may 
be  increased,  in  cases  of  rapid  course  there  appear,  together  with 
symptoms  of  cardiac  failure,  ivniitiug  and  violent  pain  in  the 
abdomen,  but  without  diarrhciea.  These  symptoms  are  ominous ; 
the  face  grows  pale  and  slightly  cyanotic ;  the  pulse  rate,  at  first 
retarded  and  irregular,  becomes  now  very  frequent  and  small ; 
dyspnoea  soon  appears,  and  death  occurs  sometimes  within  a  few 
hours  after  the  onset  of  abdominal  pains  and  vomiting. 

\'ery  much  depends  upon  the  condition  of  the  respiratory 
and  circulator}-  organs,  also  the  cry.  so  that  we  may  here  say  a 
few  words  regarding  this  symptom,  which  is  so  frequently  met 
with    m    small    children. 

A  loud  cry  after  birth  belongs  to  the  normal  and  is  a  very 
desirable  occurrence.  It  indicates  that  the  first  inspirations  are 
deep.  On  the  contrary  a  screaming,  feeble  cry  at  birth  show-s 
either  general  weakness  of  the  child  ( abortive  child),  or  it  depends 


EXAMIXAIION    OF    CHILDREN  7^^ 

Upon  the  abnormal  course  of  the  labor  as  well  as  upon  intra- 
uterine asphyxia  of  the  child,  raising  the  suspicion  of  pulmonary 
atelectasis  or  congenital  heart  lesions.  (In  close  connection  with 
the  atelectasis  is  patency  of  the  ductus  arteriosus). 

A  continued,  loud  cry  denotes  an  acute  pain  in  the  child. 
To  clear  awa}-  the  cause  of  such  crying  usually  requires  the 
further  examination  of  the  patient.  \\'hatever  the  reason  for  the 
cry  may  be,  one  must  first  of  all  strip  the  child  and  examine  not 
only  the  whole  body,  but  also  the  child-bed  linen  and  the  bed. 
The  cause  of  a  constant  restlessness  and  uneasy  sleep  may  be  a 
needle  in  the  mattress,  or  the  presence  in  the  bed  of  fleas  or  bugs. 
In  determining  the  cause  of  crying  one  must  bear  in  mind  that 
not  every  severe  pain  produces  a  loud  cry  in  a  child.  If  the  pain 
increases  under  the  influence  of  venous  stasis  or  action  of  the 
abdominal  muscles,  or  in  deep  inspiration,  then  during  such  a  pain 
the  child  avoids  a  violent  cry,  but  he  will  groan  dolefully,  whimper 
or  squeak,  but  not  cry  with  all  his  force.  On  this  account  one 
may  be  guided  by  the  cr\-  in  the  differentiation  of  headache  from 
meningitis,  pains  in  the  chest  from  pleuro-pneumonia.  and  in  the 
abdomen  during  peritonitis.  On  the  contrary  the  most  violent  cry 
in  children  accompanies : 

( I )  Acute  abscesses  in  the  subcutaneous  cellular  tissue  ( in 
the  new-born  inflammation  of  the  mammillary  glands  must  be  es- 
pecially mentioned). 

(  2)  Acute  affections  of  the  bones  and  articulations  (fracture, 
synovitis :  pathognomonic  of  these  lesions  is  a  sudden  appearance 
of  the  most  violent  cry  on  the  slightest  passive  movement  of  the 
affected  extremity). 

(3)  Colics  from  dyspepsia. 

(4)  Hindered   micturition. 

(5)  Inflammation  of  the  external  and  middle  ears. 

(6)  Starvation. 

The  first  and  second  causes  of  crying  are  determined  or  ex- 
cluded by  the  results  of  general  inspection  of  the  whole  body. 

A  cry  from  dyspeptic  colic  is  characterized  by  occurring  sev- 
eral times  during  the  day,  especially  at  night-time,  in  the  form 
of  violent  attacks,  which  suddenly  arise,  and  also  suddenly  stop. 
In  the  intervals  the  child  seems  to  be  entirely  well,  he  is  cheer- 
ful and  has  no  fever.      (A  temperature  higher  than  38  degrees 


74 


EXAMINATION    OF    CHILDREN 


Q — 100.4  degrees  F.  excludes  a  common  dyspepsia).  The  child 
often  expells  intestinal  gas  and  frequently  becomes  calm  after  the 
passage  of  flatus.  The  dejections  show  signs  of  dyspepsia  (green- 
ish color  and  admixture  of  white  lumps).  The  abdomen  appears 
on  examination  more  or  less  distended.  It  is  especially  char- 
acteristic of  the  cry  with  colics  that  it  stops  immediately  after 
a  movement  of  the  bowels,  therefore  an  enema  may  be  resorted  to 
for  diagnostic  purposes. 

If  the  dejecta  be  of  normal  color  and  consistency,  the  abdomen 
not  distended  but  soft,  fever  being  present,  then  it  is  improbable 
that  the  child  cries  because  of  colic.  The  diagnosis  of  the  latter 
is  often  assisted  from  the  child  "twisting  his  legs"  during  the 
crv,  i.  e.,  either  flexing  the  thighs  on  the  abdomen,  or  extending 
them,  rubbing  one  leg  over  the  other.  This  sign  is  of  no  special 
importance,  occurring  during  any  violent  cry. 

Crying  from  ])ain  is  most  often  met  with  in  children  imder 
three  months  of  age. 

A  (TV  which  depends  upon  paitijul  niictitrition  is  characterized 
by  the  child  crying  Ijcforc  micturition  and  growing  quiet  after 
evacuation  of  the  bladder. 

Among  the  causes  one  should  bear  in  mind  in  children  during 
the  tirst  weeks  of  life  is  the  occurrence  of  sand  in  the  kidneys 
(remnants  of  sand  on  the  pneputium  or  on  the  diaper)  and  a 
marked  phimosis.  In  order  to  become  convinced  that  crying  de- 
pends upon  bladder-spasm  one  must  examine  the  diaper.  If  it 
be  found  that  this  is  wet  every  time  at  the  end  of  crying,  then 
spasm  of  the  bladder,  as  the  cause  of  crying,  becomes  very  prob- 
able, especially  in  cases  where  dyspepsia  may  be  excluded.  Ac- 
cording to  Politzer  {'-■-)  the  diagnosis  becomes  confirmed  by  ad- 
ministering lycopodium  in  the  form  of  emulsion,  which  removes 
quickly  an  ordinary  spasm  of  the  bladder.  He  describes  a  case 
of  spasm  in  a  two-year-old  girl,  who  cried  eight  or  ten  times 
each  night  for  four  weeks  and  who  was  calmed  after  the  first  doses 
of  lycopodium. 

If  the  cry  depends  upon  ear  iiiHamDiafion,  then  it  increases 
from  pressure  upon  the  tragus  or  by  drawing  the  ear-shell  back, 
as  well  as  in  concussions  of  the  body  and  quick  movements  of  the 


*Politzer,  Jalirb.  f.  Kinderh.     1884,  p.  30. 


EXAMINATION    OF    CHILDREN  75 

•head,  and  in  deglutition  and  sucking.  Therefore  Troltsch  holds 
as  very  noteworthy  in  the  cry  caused  by  inflammation  of  the  ears 
its  appearance  each  time  as  soon  as  the  child  begins  to  take  the 
i>reast  or  the  bottle.  If  the  physician  suspects  the  cause  of  cry- 
ing to  be  a  lesion  of  the  ears,  then  he  may  confirm  his  suspicions 
•by  the  therapy,  inasmuch  as  it  often  occurs  that  such  a  cry. 
having  lasted  with  slight  intervals  the  whole  day,  stops  imme- 
-diately  after  pouring  into  both  ears  a  few  drops  of  warm  oil  or 
•cocaine  solution. 

If  the  earache  be  produced  by  furunculous  inflammation  of 
the  external  meatus,  then  the  diagnosis  is  easy  by  a  mere  inspec- 
tion. 

Pain  depending  upon  otitis  externa  or  media  is  usually  ac- 
•companied  by  fever. 

The  cry  of  hunger  is  not  difficult  to  recognize,  but  despite 
-this  it  often  remains  unappreciated  during  many  days  and  even 
weeks,  depending  upon  the  fact  that  the  physician  does  not  grant 
it  enough  attention.  To  diagnosticate  a  cry  due  to  hunger,  one 
must  maintain  the  rule  to  examine  the  breast  of  the  nursing 
Avoman  without  delay.  To  avoid  a  possible  error  one  should  in- 
vestigate the  quantity  of  milk  immediately  after  the  child  has 
•taken  the  breast.  If  then  the  milk  can  be  squeezed  out  by  drops 
only,  it  signifies  there  is  but  little  in  the  breasts,  and  znce  versa, 
if  one  succeeds  in  obtaining  streams  of  milk,  then  it  may  be  said 
positively  that  the  child's  cry  is  not  due  to  hunger  (supposing, 
of  course,  that  the  child  can  suck  the  breast  well,  or  that  a  wet- 
nurse,  being  dissatisfied  with  her  position,  does  not  stai"ve  the  baby 
intentionally).  If  there  are  weighing  scales  at  hand  the  diagnosis 
is  easier,  because,  first,  one  may  directly  determine  how  much 
milk  the  child  had  sucked  (*)  ;  and  secondly,  one  may  observe,  by  a 
daily  notation,  the  rapid  decrease  of  the  child's  weight.  If  the 
-decrease  of  weight  cannot  be  explained  either  b}-  fever,  or  by  any 
other  disease  as,  for  instance,  diarrhcea,  then  this  mere  circum- 
stance may  point  toward  starvation.  Starving  children  seldom 
pass  much  water  and  usually  sufifer  from  constipation,  although 
dyspepsia   does  not  exclude   starvation   at  all,  because  a   small 


*The   child  should  suck  out.   during  the  first  months   of   Hfe.  at  each 
aiursine  about  i-iooth  of  weight  of  his  body. 


•j6  EXAMINATION    OF    CHILDREN 

quantity  of  milk   in   the  breasts  usiiallv  corresponds  to  its  poor 

quality. 

If  one  suspects  that  the  child's  cry  is  caused  l)y  hung-er  it 
is  very  easy  to  prove  the  point,  as  it  is  only  necessary  to  feed 
the  baby  with  cow's  milk,  when,  if  starved,  he  very  soon  becomes- 
quiet  and  falls  into  a  deep  sleep  for  a  few  hours,  an  event  which 
had  probably  not  happened  for  quite  a  long  time. 

Thus,  dealing  with  a  crying  child,  one  must  strip  the  baby,, 
inspect  his  whole  body,  feel  his  ears,  ask  about  his  dejecta  and 
micturition,  examine  the  quantity  of  milk,  and,  according  to  the 
results  obtained,  administer  for  the  final  diagnosis  such  a  thera- 
peutic remedy  as  indicated. 

A  prolonged  violent  cry,  regularly  repeated  at  certain  hours,, 
depends  most  probably  upon  a  typical  neuralgia  of  malarial  origin. 
The  diagnosis  becomes  confirmed  by  the  favorable  action  of  quin- 
ine, which  is  to  be  given  four  or  six  hours  before  the  beginning 
of  the  regular  paroxysm.  In  other  cases  a  similar  periodical  cry, 
especially  after  midnight,  may  depend  u])on  the  beginning  of 
spinal  meningitis  due  to  caries  of  the  vertebral  cohnnn. 

A  short,  violent  cry,  or  a  loud,  monotonous  screaming,  noted 
in  a  child  which  is  in  a  somnolent  condition,  occurs  most  often  in. 
acute  hydrocei)halus  and  hydrocephaloid  (see  the  corresponding- 
section)  and  therefore  is  called  clamor  ccf^halicits  (cephalic 
cry  ) . 

( )f  entirely  diti'erent  import  is  the  night  cry.  of  two  or  three 
minutes  duration,  in  children  five  to  eight  \ears  of  age  apparent- 
ly in  good  general  health.  Such  a  cry  is  accompanied  by  a 
frightened  expression  of  the  face  and  becomes  repeated  either 
each  night,  or  after  several  nights,  but  almost  always  during  the 
first  hours  of  sleep.  It  is  peculiar  of  so-called  night-terror.  Ac- 
cording to  Politzer  the  certain  and  rapid  action  of  quinine,  five 
or  eight  grains,  two  hours  before  sleep,  given  several  days  in  suc- 
cession, is  also  helpful  in  the  diagnosis  of  night-terror. 

Crying  during  defecation,  associated  zcith  fear  of  tliis  act, 
together  with  persistent  constipation,  may  be  held  as  a  pathogno- 
monic symptom  of  anal  fissure.  In  one  of  my  cases,  in  a  three- 
year-old  girl,  "the  fear  of  the  toilet"  was  noticed  not  before  defe- 
cation, but  with  each  micturition,  which  was  accompanied  each. 


EXAMINATION    OV    CiriLDRICN  7- 

*ime  by  crying-.  The  cause  of  the  latter  was  found  in  superficial 
erosions  on  the  inner  surface  of  the  labia  majora. 

The  character  of  the  voice  is  also  important  in  diagnosis. 
A  hoarse  voice  denotes  an  affection  of  the  larynx.  In  acute  cases 
•either  a  catarrh  or  croup  may  be  indicated,  in  chronic  cases,  how- 
ever, syphilis  is  thought  of  first  of  all.  In  children  of  a  few  weeks 
■of  age,  the  hoarse  voice  is  the  result  of  a  too  loud,  almost  con- 
tinual cry,  which  lasted  a  couple  of  days.  Such  a  cry  hardly 
•ever  occurs  in  common  colics  but  often  depends  upon  hunger  or 
the  formation  of  an  abscess  in  some  place  (mastitis),  or  upon 
lesion  of  the  ears. 

A'asal  voice  (snuffling)  is  met  with  in  all  cases  of  paralysis 
of  the  soft  palate  after  diphtheria  and  very  often  in  retro- [pharyn- 
geal abscess,  as  well  as  in  cleft  palate,  in  an  obstructed  nose  and 
sometimes  in  hypertrophy  of  the  tonsils. 

The  important  diagnostical  meaning  of  cougli  results  from 
the  fact  that  it  directly  points  toward  an  affection  of  the  respira- 
torv  organs.  In  many  cases  one  may  get  an  idea  of  the  situation 
and  the  nature  of  the  disease  from  the  character  of  the  cough. 
As,  for  instance,  if  the  cough  appears  in  violent  attacks,  inter- 
rupted by  whistling  inspiration,  and  consisting  of  a  ivhole  series 
of  coughing  spells,  following  each  other  in  succession  without  rest, 
and  ending  with  vomiting  or  expidsion  of  viscid  sputum,  we  shall 
hardly  make  a  mistake  in  saying  the  patient  is  suffering  with 
whooping-cough  (regarding  the  possibility  of  error  see  Whoop- 
ing-cough). 

A  short,  hoarse,  so-called  "'ringing  cough"  denotes  a  false  or 
true  croup. 

In  bronchitis  we  judge  the  period  of  the  disease  from  the 
character  of  the  cough  ;  if  the  cough,  being  dry  and  frequent, 
interferes  with  the  patient's  sleep,  then  we  speak  of  the  first  period 
-of  bronchitis  ;  in  the  event,  however,  of  moist  cough,  then  of  the 
resolution  of  the  catarrh.  A  short,  painful  cough,  accompanied 
by  discomposure  of  the  face,  or  by  sighing,  denotes  pneumonia 
•or  pleurisy. 

Examination  of  the  sputum  in  childhood  is  of  the  same  im- 
portance as  in  adults :  but  as  children  under  five  years,  and  fre- 
quently even  elder  ones,  usually  swallow  the  sputum,  it  is  some- 
times difficult  to  get  it  for  examination.     If  a  small  child,  accord- 


yS  EXAMINATION    OF    CHILDREN 

ing  to  the  observation  of  the  parents,  expectorates  the  sputurtr 
each  time  after  coughing,  then  this  is  in  favor  of  whooping- 
cough. 

Blood  in  the  expectoration  of  children  is  very  seldom  met 
with,  because  the  most  frequent  cause  of  hsemoptysis  in  adults — 
consumption — occurs  in  children  without  bloody  expectoration.  In 
older  children  haemoptysis  occurs  almost  exclusively  in  cardiac 
lesions,  and  very  much  more  seldom  in  purpura.  A  small  admix- 
ture of  blood  in  sputum  occurs  sometimes  after  the  attacks  of 
severe  cough  in  bronchitis,  and  especially  in  pertussis.  More  often 
there  is  noted  some  blood  not  in  the  expectoration,  but  in  the 
saliva.  Such  a  bloody  discharge  occurs  in  ulcerous  stomatites^ 
especially  in  stomacace,  as  well  as  in  diphtheria  of  the  fauces. 

Inspecting  the  abdomen  attention  must  be  devoted  to  its- 
size  and  shape.  Normally,  i.  e.,  if  the  abdomen  be  neither  dis- 
tended, nor  sunken,  its  anterior  and  lateral  walls,  in  the  recum- 
bent posture  of  the  patient,  must  be  on  the  level  of  the  inferior 
margin  of  the  chest,  that  is,  the  abdominal  walls  seem  to  be  an 
immediate  continuation  of  the  chest.  About  the  semeiology  of 
the  distended  abdomen  I  shall  speak  in  a  particular  part ;  but  with 
regard  to  the  sunken  abdomen  it  may  be  said  that  this  symptom 
is,  by  itself,  of  no  other  importance  than  showing  a  small  amount 
of  gases  in  the  intestines,  which  in  adult  persons  signifies  a  good 
digestion.  Especial  importance  should  be  attached  to  the  sunken 
abdomen  only  in  the  presence  of  some  other  symptoms,  as,  for 
instance,  if  the  child  suffers  from  diarrhoea,  then  the  sunken 
abdomen  denotes  the  too  rapid  elimination  of  gases.  This  is- 
usually  observed  in  very  frequent  evacuations  of  the  bowels,  oc- 
curring especially  in  nuicous  or  blood>-  diarrhoea.  Therefore  a 
sunken  abdomen  occurs  much  oftener  in  follicular  enteritis  than  in 
catarrh  of  the  small  bowels. 

If  the  sunken  abdomen,  in  spite  of  constipation,  be  observed 
in  a  febrile  patient  in  whom  the  course  of  the  temperature  and 
other  data  are  in  favor  of  typhoid,  then  the  mere  absence  of 
meteorismus  should  raise  the  physician's  suspicion  of  possibility  of 
tubercular  meningitis.  The  suspicion  becomes  a  positive  fact 
if  the  patient  becomes  sonmolent,  despite  the  temperature  being" 
comparatively  low  (below  39  degrees  C. — 102.2  degrees  F.).  In 
small  and  rachitic  children,  in  whom  the  abdomen  is  large,  it  re- 


EXAAriNATKt.X     ()!■     illllDRKN 


79 


mains  somewhat  enlarged  even  in  the  period  of  well-developed 
meningitis,  but  here  it  is  important  to  note  the  considerable  soft- 
ness of  the  abdomen  and  the  tendency  of  its  walls  to  yield,  so  that, 
despite  some  meteorismus,  one  often  succeeds  in  reaching-  the 
vertebral  column  by  the  palpating  fingers.  Such  a  softness  of 
the  abdomen  has  the  same  diagnostic  importance  as  the  sunken 
abdomen  in  adult  persons. 

Furthermore,  in  inspecting  the  abdomen  of  small  children 
we  regard  the  condition  of  the  navel.  Normally  the  remnants  of 
the  umbilical  cord  become  mummified  and  fall  ofif  on  the  fifth  day 
(in  abortive  children  and  when  Wharton's  jelly  is  too  thick — 
somewhat  later).  The  process  of  minnmification  must  not  be  ac- 
companied b}^  an  odor,  which  denotes  suppuration  of  the  cord 
and  depends  most  often  upon  improper  care  of  the  funiculus, 
when,  for  instance,  this  is  wrapped  in  an  oily  rag-  and  thus  its 
drying-up  is  prevented.  After  sloughing  off  the  cord  exhibits 
a  suppurating  surface  circumscribed  by  a  small  area  of  slightly 
inflamed  skin.  This  umbilical  wound  usually  heals  about  the 
end  of  the  second  week,  but  it  may  suppurate  even  longer  with- 
out being  abnormal,  provided  the  reactive  inflammation  is  not  in- 
creased, that  is,  neither  the  quantity  of  the  secretion,  nor  the 
redness  of  the  skin,  increase ;  otherwise  we  have  ulceration  or 
excoriation  of  the  umbilicus.  If  the  suppurating  umbilical  wound 
spreads  over  the  adjacent  surface,  discharges  malignant  pus,  or 
becomes  covered  as  if  with  false  membranes,  then  it  is  spoken  of 
as  an  umbilical  sore,  or  croup  and  diphtheria  of  the  navel  (local 
infection).  If  at  the  same  time  infiltration  of  the  connective  tis- 
sue appears  around  the  navel  (bright  redness,  solid  swelling  and 
painfulness  upon  pressure  in  the  region  of  the  umbilicus),  to- 
gether with  a  febrile  condition,  then  we  have  inflammation  or 
phlegmon  of  the  navel  (infection  of  the  connective  tissue  around 
the  navel) — omphalitis. 

Such  a  condition  of  the  navel  is  ominous  for  the  patient's 
life,  as  the  inflammation  may  easily  spread  to  the  perivascular 
connective  tissue  of  the  umbilical  vessels,  when  periarteritis  or 
periphlebitis  umbilicalis  supervenes,  with  subsequent  pyaemia  or 
septicaemia. 

Inflammation  of  the  umbilical  vessels  is  not  easy  to  be  recog- 
nized, because  there  are  usually  no  local  symptoms  which  would 


-80  EXAMINATION    OF    CHILDREN 

be  especially  indicative  of  this  affection.  The  assertion  of  some 
authors  about  the  redness  of  the  skin  along  the  course  of  the 
arteries  does  not  become  verified  in  the  majority  of  cases. 

One  may  suspect  inflammation  of  the  umbilical  vessels  in  all 
cases  where,  the  navel  being  inflamed,  the  child  begins  to  mani- 
fest fever,  and  when  there  quickly  develops  collapse ;  or  where 
local  symptoms  of  pyaemia  appear  in  the  form  of  subcutaneous 
abscesses,  inflammation  of  the  joints,  of  the  serous  membranes, 
•etc. 

In  short,  periarteritis  occurs  much  oftener  than  ])eriphlebitis  ; 
therefore,  in  the  presence  of  the  above-named  symptoms,  there 
is  more  probability  of  the  afl'ection  of  the  arteries ;  but  if  at 
the  same  time  severe  jaunduce  be  noticed  it  is  a  symptom  of  peri- 
phlebitis. 

If  a  spherical  tumor,  the  size  of  a  pea,  be  noted  during  the 
inspection  of  a  continuing  suppuration  of  the  navel,  which  is 
pedunculated  and  bleeds  easil}'  upon  touch,  then  such  a  tumor, 
caused  by  growing  granulations,  is  known  as  umbilical  fungus 
— fungus  umbilici,  s.  sarcomphalus. .  Left  without  any  treatment 
the  tumor  continues  suppurating  for  a  few  months  and  may  reach 
the  size  of  a  walnut,  but  finally  becomes  covered  with  scars  or 
sloughs  off. 

The  umbilicus  is  sometimes  the  source  of  an  abundant 
haemorrhage  of  two  kinds,  arterial  and  parenchymatous  umbili- 
cal haemorrhage.  The  former  is  observed  in  children  when  the 
cord  is  not  ligated  firmly,  lilood  also  appears  from  the  umbilical 
vessels  before  the  sloughing  of  the  cord,  but  may  be  easily  checked 
by  applying  a  new  ligature.  On  the  contrary  parenchymatous 
haemorrhage  is  very  persistent.  It  always  depends  upon  a  gen- 
eral disease  of  the  organism,  the  so-called  temporary  hccmophilia: 
under  the  influence  of  which  hccmorrhages  also  occur  from  other 
■organs  (mucous  membrane  of  the  mouth,  gums,  vulva,  etc.,)  and 
under  the  skin.  Parenchymatous  haemorrhage  usually  begins 
about  the  fifth  day  and  in  the  great  majority  of  cases  (eighty  to 
ninety  per  cent.)   ends  fatally  in  a  few  days. 

Temporary  haemophilia  may  be  the  consequence  of  inherited 
syphilis,  general  sepsis  and  acute  fatty  degeneration  of  the  new- 
liorn.  The  latter  malady  is,  post-mortem,  characterized  by  paren- 
chymatous degeneration  of  the  viscera  and  haemorrhages  in  the 


EXAMINATION    OF    CHl[J)RI-:x  Si 

skin,  serous  nitMnl)rancs  ami  viscera.  Clinically  the  disease  mani- 
fests itself  by  icterus  and  different  haimorrhag-es,  while  the  tem- 
perature  fre^iuently    remains   normal. 

If  the  umbilicus  be  much  protruded  this  may  depend  either 
upon  an  uiiiblllcal  hernia  or  upon  the  superfluity  of  the  skin — 
cutaneous  uinhilicus.  In  the  fortuer  case  the  tumor  has  a  spheri- 
cal shape,  reaching-  the  size  of  a  walnut  or  that  of  a  nut-gall. 
Still  larger  umbilical  herniae  assume  conical  or  pyriform  shapes. 
Upon  compression  with  the  fingers  this  tumor  mav  be  easilv  re- 
duced through  the  umbilical  ring  into  the  abdominal  cavitv,  but 
during  the  cry  it  appears  again.  In  the  case  of  cutaneous  um- 
bilicus it  appears  like  a  cylindrical  supplement,  which  does  not 
change  from  pressure  and  cannot"  be  reduced ;  furthermore  the 
shape  and  size  of  the  navel  do  not  change  during  the  cry. 

After  inspection  one  proceeds  to  the  cxainijuifioii  of  the 
abdomen  by  palpatiui^.  Normally  the  abdomen  in  children  when 
palpated  makes  an  impression  as  of  an  elastic  pillow  which  is 
moderately  inflated  with  air.  An  exception  to  this  rule  is  found 
in  children  of  the  first  months  of  life,  in  whom  even  normally 
the  liver,  and  especially  the  spleen,  may  often  be  palpated.  If 
some  hardening,  or  tumor,  be  palpated  in  an  elder  child,  then 
this  is  at  once  an  abnormality,  pointing  either  toward  an  enlarge- 
ment or  induration  of  one  of  the  abdominal  organs  (liver,  spleen, 
lymphatic  glands,  kidneys),  or  to  a  new  growth  of  inflammatory 
or  other  origin. 

Palpating  the  abdomen  is  done  in  the  recumbent  posture  of 
the  patient.  The  physician  applies  the  plantar  surface  of  his  hands 
to  the  abdomen,  using  slight  pressure  with  the  ends  of  his  fingers 
(by  the  soft  parts  of  the  third  phalanges),  until  the  child  makes 
an  inspiration.  During  expiration  the  abdominal  wall  becomes 
relaxed  and  then  it  is  possible  to  feel,  by  the  sinking  fingers,  any 
undue  firmness  in  the  abdominal  cavity,  provided  the  former  be  at 
the  place  of  pressure  by  the  hand.  When  the  child  is  crying  then 
the  best  moment  for  palpation  is  during  the  deep  inspiration : 
but,  as  this  moment  is  too  short,  one  must  have  considerable 
experience  to  successfully  palpate  a  crying  child,  and  even  then 
only  the  more  pronounced  anomalies  can  be  detected. 

In  determining  the  lower  border  of  the  liver  or  spleen  one 
should  begin  the  examination  from  below,  for  instance  from  the 


82  EXAMINATION    OF    CHILDREN 

level  of  the  umbilicus,  and  then  move  the  fingers,  during  each  in- 
spiration, one  or  two  inches  higher.  Such  a  method  of  gradual 
moving  of  the  fingers  is  recommended  because  palpating  the 
margin  of  an  organ  is  much  easier  than  its  surface.  In  many 
cases  of  not  very  pronounced  hardening  of  the  liver  or  spleen 
their  surfaces  are  not  palpable  even  when  their  edges  are  easily 
felt. 

We  also  employ  palpation  of  the  abdomen  for  estimating  the 
tension  of  the  abdominal  walls  (in  cases  of  limited  transudations 
in  the  abdominal  cavity  there  is  relaxation  of  the  abdominal 
muscles;  in  exudation  there  is  tension)  and  for  determining 
fluctuation. 

By  percussing  the  abdomen  we  may  learn  the  boundaries  of 
the  organs  (see  Diseases  of  the  Liver  and  Spleen),  the  degree 
of  distention  of  the  bladder,  the  thickness  of  tumors  palpable 
through  the  abdominal  wall  (inflammatory  infiltrations  in  the 
abdomen  and  omentum  sometimes  make  an  impression  of  vol- 
uminous tumors,  but,  due  to  their  insignificant  thickness  they  give 
on  percussion  a  tympanitic  note,  by  which  they  decidedly  differ 
from  solid  new-growths  which  have  their  origin  in  the  retro- 
peritoneal glands,  kidneys  or  ovaries).  By  percussion  we  find  out 
also  the  quantity  of  fluid  in  the  abdominal  cavity  (by  the  upper 
border  of  the  dull  sound). 

Inspection  of  the  extremities  may  furnish  very  important 
data  in  different  directions,  as,  for  instance,  peculiar  curvatures 
of  the  bones  allow  us  to  make  an  exact  retrospective  diagnosis 
between  an  old  rachitis  and  late  hereditary  syphilis  (see  descrip- 
tion of  the  latter).  Characteristic  scars  appear  during  many  years 
as  true  signs  of  an  antecedent  carious  process.  Deficiency  in  the 
unilateral  grow^th  of  the  extremities,  the  muscles  being  well  con- 
served, occurs  in  chronic  abscesses  of  the  brain.  Thickness  of  the 
third  phalanges  of  the  hands  undoubtedly  shows  a  permanent 
hindrance  to  circulation  due  to  a  cardiac  lesion,  or  to  a  purulent 
pleurisy,  which  was,  perhaps,  cured  long  ago. 

Our  observations  have  convinced  us  that  beginners  meet  with 
most  difficulty  in  the  diagnosis  of  nervous  diseases,  which  de- 
pends, perhaps,  upon  a  poor  acquaintance  \vitli  the  methods  of 
examination  of  such  patients,  largely  because  these  methods  are 
not  very  commonly  used  in  pediatric  clinics.    In  discussing,  there- 


EXAMINATION    (il"    CUILDREX  85 

fore,  the  examination  of  the  nervous  system  I  will  enumerate 
more  minutely  those  points  to  which  one  must  especially  pay  at- 
tention when  dealing-  with  the  diseases  of  the  nervous  svstem. 

Of  the  suhjective  symptoms  essentially  important  are  dizzi- 
ness, headache,  variahle  painful  sensations  in  other  places,  anies- 
thesia,  paresthesia,  etc.  In  the  objective  examination  one's  at- 
tention is  called  to  the  expression  of  the  face,  condition  of  the  men- 
tal abilities,  ability  of  speech  (naming  of  surrounding  objects, 
counting,  loud  reading,  writing — from  dictation  and  spontaneous- 
ly) the  understanding  of  speech,  writing  and  gestures.  Upon 
examination  of  the  motor  apparatus  attention  should  be  given  to 
the  gait  and  the  posture  of  the  body,  to  the  condition  of  the  nutri- 
tion antl  muscular  tonus  (atroj)hy  or  hypertroph\-  of  the  muscles  : 
their  rigidity  or  complete  relaxation,  flabbiness),  active  move- 
ments, strength  of  the  hands  (dynamometer)  and  of  the  legs;  co- 
ordination of  movements  (  standing  or  walking  with  closed  eyes  ; 
tremor  during  active  movements  and  during  rest ;  choreic  tremor 
and  fibrillar  contractures)  ;  clonic  and  tonic  convulsions  and  con- 
tractures ;  reflexes  from  the  mucous  membranes  (winking,  sneez- 
ing, contraction  of  the  uvula)  ;  cutaneous  reflexes;  abdominal  re- 
flex (contraction  of  the  muscles  of  the  abdominal  wall  when  a 
line  is  drawn  over  the  skin  of  the  abdomen  by  the  nail  or  handle 
of  the  hammer),  cremaster  reflex  (elevation  of  the  testicle  toward 
the  inguinal  canal  upon  irritation  of  the  inner  surface  of  the 
thigh)  ;  the  sole  and  tendon  reflexes,  especially  from  the  tendon 
of  the  extensor  of  the  leg  (patellar  reflex,  or  "knee-jerk"),  as 
well  as  from  the  triceps  and  Achilles  tendon  (ankle-clonus)  ;  the 
mechanical  irritability  of  the  nerves  and  muscles. 

Examining  the  sensibility  one  notes  the  response  to  contact,, 
pain,  localization,  temperature  and  pressure,  while  especial  atten- 
tion should  be  given  to  the  sense  of  pressure  on  the  nerve  branches 
and  muscles. 

About  the  condition  of  the  so-called  muscular  sense  we  judge 
by  estimating  the  weight  of  things  and  by  passive  movements,  by 
the  ability  of  determining  the  position  of  the  limbs  and  by  per- 
forming movements  with  the  closed  eyes. 

Further  follows  the  examination  of  functions  of  the  cerebral 
nerves.  I,  Smelling,  II,  vision  (subjective  sensations,  acuteness 
and  field  of  vision,  ophthalmoscojiic  examination);    III.    l\'  and 


84  EXAMINATION    OF    CHILDREN 

VI,  movements  of  the  eye-balls  (strabismus,  ptosis,  nystagmus, 
the  size  of  the  pupils  and  their  reaction  to  light  and  accommoda- 
tion) ;  y,  sensibility  of  the  face;  taste;  VII,  movability  of  the 
muscles  of  the  face  and  of  the  soft  palate;  VIII,  hearing;  IX, 
taste  on  the  posterior  half  of  the  tongue ;  X,  sensibility  of  the 
pharynx  and  oesophagus ;  disturbances  on  the  part  of  the  heart 
and  respiration ;  X  and  XI,  paralysis  of  the  pharynx  and  laryngeal 
muscles ;  XI,  paralysis  of  the  sterno-cleido-mastoid  muscle  and 
trapezius  and,  XII,  the  tongue.  The  examination  is  ended  with 
information  alx)ut  the  vesical  and  rectal  functions  (frequency  of 
the  desire  to  pass  water,  the  night  and  da\-  incontinence,  retention 
of  the  urine),  vasomotor,  tr()])hical  and  secretory  disorders. 

In  examining  the  i^ctiifo-iirliiary  ori:;aiis  attention  should  be 
given  to  the  condition  of  the  external  genital  organs,  and  when 
there  is  complaint  of  painful  micturition  particular  regard  must 
be  devoted  to  the  condition  of  the  praejiutium  (piiimosis,  balani- 
tis). In  retention  of  the  urine  one  examines,  by  palpating,  the 
urethra  for  an  impacted  stone,  and  in  the  case  of  absence  of  the 
latter,  proceeds  to  the  catheterization  of  the  bladder.  To  the 
semeiology  of  micturition  we  shall  devote  a  separate  part,  but 
we  will  say  a  few  words  here  about  the  examination  of  the  urine. 

Normally  the  urine  in  children,  except  in  the  new-l^orn,  ex- 
hibits in  general  the  same  properties  as  in  adults.  It  is  of  straw- 
yellowish  color,  entirely  clear  and  transparent,  does  not  give  any 
deposit  when  fresh,  is  of  faintly  acid  reaction,  specific  gravity 
about  1005  to  loio,  and  is  voided  in  larger  quantities  the  older  the 
child.  One  may  say  approximately  that  from  one  up  to  five  years, 
150  grams  for  each  year  is  voided  in  twenty-four  hours  ;  from  five 
up  to  ten  years,  125  grams  in  twenty-four  hours. 

In  children  in  the  first  year  of  life  the  urine  is  distinguished 
b)y  its  very  pale  color  and  low  specific  gravity  (about  1002)  ;  in 
new-born,  on  the  contrary,  the  urine  is  cloudy  from  the  admixture 
of  mucus,  epithelium  and  uric  acid  salts,  usually  containing  during 
the  first  eight  or  ten  days  albumen  and  casts  (physiological  hype- 
rsemia  of  the  kidneys). 

Examination  of  children's  urine  is  performed  according  to 
the  same  methods  as  in  adults  ;  therefore  it  would  be  superfluous 
to  here  enter  into  minute  descriptions.  We  shall,  therefore,  only 
point  out  some  sources  of  error  in  determining  the  presence  of 


EXAMINATION    OF    t  1 1  I  LI  )Ki:\  S5 

albumen  in  the  urine  l)y  means  of  eommon  methods.  He  wlio 
ignores  the  possiliihty  of  sueh  errors  mav  not  find  albumen  even 
where  it  is  jiresent  in  great  quantities,  or.  I'icc  versa,  he  will  find 
albuminuria  in  normal  urine. 

It  is  known  that  upon  boiling  an  alkaline  urine  we  do  not 
get  any  albumen  reaction,  therefore  it  is  advised  in  all  text-books 
to  acidif\'  the  urine  by  adding  acetic  or  nitric  acids  ;  further  it  is 
mentioned  that  the  albumen  becomes  dissolved  upon  boiling  when 
there  is  superfluity  of  acid,  so  that  reaction  fails,  and  one  must 
therefore  add  to  the  urine  but  a  few  drops  of  the  reagent.  I  Jut 
there  is  one  fact  which  1  have  met  occasionally,  and  which  is  not 
ex])lained  by  any  literary  data :  one  or  two  drops  of  pure  nitric 
acid  to  a  feiv  cubic  centimeters  of  acid  urine,  does  not  allow  the 
albumen  to  coagulate  when  heated,  so  that  urine,  even  ^'cry  rich 
with  albumen  and  of  7'ery  stroui^  acid  reaction,  remains  absolutely 
transparent ;  but  if  some  more  drops  of  the  same  acid  be  added, 
then  the  test  succeeds  admirably,  as  well  as  without  any  addition 
of  acid.  (*)  These  experiments  have  been  conducted  l)efore  my 
students  and  colleagues  of  the  hospital. 

It  is  thus  obvious  that  it  may  readil_\'  (xxnu"  that  albumen  will 
not  be  found,  in  spite  of  a  considerable  albumimiria. 

Furthermore  it  is  well  known  that  turbidity  of  the  urine  which 
is  obtained  upon  a  mere  addition  of  nitric  acid  without  boiliiii^ 
does  not  yet  prove  the  presence  of  albumen  in  the  urine,  because 
such  a  reaction  may  be  obtained  from  propepton  (very  seldom) 
or  from  uric  acid  salts  (often).  In  both  cases  the  urine  becomes 
clear  again  when  heated  ;  however,  if  the  turbidity  depends  upon 
albumen  then  upon  heating  not  only  does  it  not  disappear,  but 
even  increases,  and  flakes  of  albumen  are  obtained.  Therefore  in 
the  text-books  it  is  recommended  to  use  not  only  the  nitric  acid 
test,  but  also,  for  controlling,  the  heat  test. 


*If  there  is  much  albumen  in  the  urine,  then  every  drop  of  nitric  acid 
causes  cloudmess  even  without  boiling,  but  this  turbidity  disappears  on 
the  further  addition  of  urine.  If  there  be  added  so  much  urine  that  shak- 
ing does  not  remove  the  turbidity,  then  the  boiling  gives  a  positive  resu't, 
that  is.  the  urine  becomes  more  turbid,  and  flakes  of  albumen  arc  formed. 
For  the  obtaining  of  a  negative  result  one  may  add  the  acid  by  drops  ^mly 
tin  the  urine  remains  clear  after  shaking.  My  observations  are  referred 
to  the  urine  in  acute  nephritis  after  scarlatina:  in  one  case  of  all)uminuria 
in  diphtheria  a  negative  result  was  not  obtained  from  adding  any  amount 
of  acid. 


86  EXAMINATION    OF    CHILDREN 

This  advice  is  understood  by  many  to  mean  that  a  new  por- 
tion of  urine  must  be  taken  in  a  test-tube  and  heated.  In  the  case 
of  a  positive  result  (appearance  of  cloucUness)  the  presence  of 
albumen  in  the  urine  is  held  as  proven.  lUit  a  new  mistake  may 
here  take  place,  because  tlie  presence  of  ph.osphates  may  give 
cloudiness  or  even  a  deposit  upon  boiling,  and,  as  the  urine  some- 
times contains  great  quantities  of  both  urates  and  jihosphates  sim- 
ultaneously, both  these  tests,  taken  separately  may  give  a  positive 
result,  in  spite  of  the  complete  absence  of  albuminuria.  It  is,  of 
course,  very  easy  to  avoid  an  error,  and  that  that  end  one  must  ob- 
tain both  reactions  zcith  the  same  portion  of  urine,  that  is,  first 
boil,  then  add  acid  (acetic  or  nitric). 

The  estimation  of  the  temperature  in  children  is.  as  in  adults, 
efifected  by  means  of  a  maximal  or  a  common  medical  thermometer 
(Celsius  or  Fahrenheit). 

The  (|uickest  and  at  the  same  time  the  most  e.xact  method 
of  measuring  temperature  consists  in  placing  the  thermometer  in 
the  rectum,  the  child  being  placed  on  a  pillow,  on  the  mother's 
knees,  in  a  recumbent  posture  on  the  side  with  the  back  directed 
forward.  The  bulb  of  the  thermometer  is  covered  with  some  fat 
and  introduced  in  the  rectum  one-and-a-half  or  two  inches  (the 
deeper  the  instrument  is  introduced,  the  better,  because  so  much 
the  quicker  will  the  mercurial  column  ^-each  the  maximal  ])oint  of 
given  temperature).  If  only  the  bulb  of  the  thermometer  be 
placed  in  the  rectum,  then  the  time  required  will  be  about  five 
minutes ;  if,  however,  the  thermometer  is  introduced  at  least  two 
inches,  then  two  minutes  will  suffice.  While  the  thermometer  is  in 
the  rectum  one  must  hold  the  child  in  such  a  manner  that  he  can- 
not break  it  by  a  rapid  movement.  The  instrument  must  also  be 
supported,  otherwise  it  will  slip  out. 

Measuring  in  the  axilla  requires  a  longer  period  of  time, 
therefore  this  method  is  recommended  only  for  children  of  more 
advanced  age,  who  have  patience  enough  to  keep  the  thermometer 
///  situ  during  a  certain  period. 

For  small  children  with  puffy  hands,  in  spite  of  protest  of 
some  German  physicians,  I  again  recommend  taking  the  tempera- 
ture in  the  axilla  by  means  of  a  i<:arnied  thermometer,  by  wdiich  I 
observe  not  the  elevation  of  the  mercurial  column,  but  its  fall. 
After  one  minute  the  mercury  falls  from  a  certain  height  and  ap- 


EXAMIXATFON    OF    CllILDRILX  S/ 

preaches  very  closely  the  c(M-rect  temperature  of  the  patient.  The 
liability  to  mistake  is  less  the  higher  the  fever  is,  and  the  latter 
being,  for  instance,  39.5  degrees  to  40  degrees  C.  ( 103  F.  to  104 
degrees  F.),  it  is  equal  approximately  too.i  to  0.2  C.  (0.13  to  0.36 
F".  degrees),  and  in  lower  degrees  to  0.3  degrees  C.  (0.5  degrees 
F.).  This  method  requires  some  experience  in  warming  of  the 
bulb  of  the  thermometer  and  great  accuracy  in  placing  the  ther- 
mometer under  the  axilla.  Warming  of  the  thermometer  is  ac- 
complished by  rubbing  its  lower  end  with  the  dr)-  hand  or  a 
blanket,  etc.,  by  which  means  it  is  possible  to  bring  the  mercurial 
column  up  to  43  degrees  C.  (109.4  degrees  F".)  in  a  half-minute. 
When  this  is  done  the  thermometer  is  quickly  placed  in  the  pre- 
pared axilla  (that  is,  the  collar  of  the  shirt  must  be  unbuttoned, 
but  the  axilla  must  be  closed  by  the  adducted  arm ;  otherwise, 
under  the  influence  of  free  air  the  skin  becomes  too  cool,  pro- 
ducing inaccurate  results).  The  mercury  immediately  begins  to 
fall,  so  that  the  measuring  may  be  determined  in  one  or  two 
minutes.  In  some  cases  the  mercury  sinks  so  slowly  that  after 
one  minute  it  is  higher  than  it  should  be,  reaching  the  proper  level 
only  after  two  or  three  minutes,  while  in  other  cases  it  sinks 
so  quickly  that  after  two  minutes  it  is  perhaps  somewhat  too  low. 
In  view  of  such  occurrences,  which  cannot  be  foreseen,  we  may 
compare  the  indication  of  the  thermometer  after  one  minute  with 
that  after  two,  and  then  take  the  average  between  them.  For 
instance,  if  it  shows  after  one  minute  39.5  degrees  C.  (103.1  de- 
grees F.),  and  after  two  minutes  39.3  degrees  C.  (102.7  degrees 
F.),  then  it  may  be  accepted  that  the  patient's  real  temperature 
is  39.4  degrees  C.  (102.9  degrees  F.).  If  the  height  of  the  mer- 
curial column  was  not  altered  during  the  second  miniUe.  then  U 
means  that  the  exact  result  was  obtained  after  one  minute. 

Although  this  method  cannot  be  held  as  an  entirely  exact 
one,  nevertheless  it  gives  results  which  are  sufficient  for  the  pur- 
poses of  a  practitioner,  because  a  mistake  of  o.  r  degree  to  0.2 
degrees  cannot  be  of  great  importance. 

[It  should  be  remembered  that  the  temperature  of  the  new- 
born does  not  at  once  assume  a  constant  normal  equilibrium,  but 
rather  fluctuates  for  several  days,  under  varying  conditions  of 
environment  until  it  finally  settles  down — so  to  speak — to  the 
physiological   standard.      No  doubt   this  variation   of   the  bodily 


»e  EXAMINATION    OF    CHILDREN 

temperature  depends  upon  the  imperfect  development  of  the  power 
of  heat  regulation — of  heat  production  and  heat  conservation. 
Babak  (*)  has  recently  shown  by  a  series  of  experiments  that 
newly-born  infants  register  a  comparatively  low  temperature  even 
when  well-clothed  and  under  ordinary  domicile  surroundings.  For 
instance,  infants  an  hour  or  two  old,  in  a  room  showing  an 
atmospheric  temperature  of  59  degrees  F.  may  exhibit  a  body 
temperature  as  low  as  93.2  degrees  F.  The  bodily  heat  gradually 
rises,  however,  during  the  first  few  days,  yet  with  considerable 
irregularity.  It  may  be  said  that  at  least  a  week  is  required  before 
the  temperature  reaches  a  level  of  constancy — a  state  of  adjust- 
ment. The  practical  point  here  is  in  connection  with  the  thorough 
protection  of  the  child  from  cold,  not  alone  in  the  maintaining  a 
proper  temperature  of  the  apartment,  but  in  the  clothing  of  the 
infant  (quality  and  quantity)  and  also  in  the  daily  baths,  which 
should  be  hot  and  carried  out  with  the  very  least  amount  of  ex- 
posure.— Earle.  j 

*Arch.  f.  d.  gcs.  Physiol..  Bonn,   1902. 


DISEASES   OF  THE  DIGESTIVE  ORGANS 

DISEASES  OF  THE  xMOUTH. 

Diseases  of  the  mouth  occur  in  children  very  often  and  at 
any  age.  Some  of  these  diseases  are  entirely  spontaneous,  while 
others  appear  only  as  symptoms  of  coincident  diseases,  especially 
of  general  ones,  and  then  they  may  considerably  assist  in  the  diag- 
nosis of  the  latter,  as,  for  instance,  in  syphilis,  scarlet-fever,  mea- 
sles, etc. 

DISEASES      OF      THE      MOUTH      UNACCOMPANIED 

EITHER  BY  THE  FORMATION  OF  ULCERS  OR  AN 

OFFENSIVE  OROR. 

Stomatitis  erythematosa,  s.  catarrJialis, — the  catarrhal  in- 
flammation of  the  mouth  in  nurslings  manifests  itself  by  a  redden- 
ing of  the  mucous  membrane  of  the  tongue  and  gums  and  by  sali- 
vation. This  disease  occurs  very  often  in  children,  preceding  the 
development  of  thrush  or  accompanying  dentition.  The  child 
grows  irritable,  capricious,  sleeps  uneasily  and  has  some  fever. 
This,  the  so-called  tooth  fever,  in  some  children  attains  such 
a  high  degree,  that  convulsions  occur.  However,  such  complica- 
tions in  reality  occur  infrequently,  inasmuch  as  the  fever  in  stom- 
atitis erythematosa  is  not  great,  usually  disappearing  in  about 
three  days. 

In  older  children  some  swelling  of  the  tongue' may  be  noted 
sometimes,  so  that  marks  of  the  teeth  are  obtained  on  its  edges  in 
the  form  of  small,  but  distinctly  noticeable,  impressions.  The 
tongue  being  at  first  red  very  soon  becomes  covered,  because  of 
increased  proliferation  of  the  epithelium  and  diverse  fungi,  by 
a  more  or  less  thick,  whitish-yellow  or  grayish  coating,  which 
makes  it  look  like  felt,  and  occupies  its  whole  upper  surface  ex- 
cluding the  margins  and  the  end — coated  tongue.  The  severer  the 
catarrh  of  the  mouth,  the  more  the  tongue  is  coated  and  the 
quicker  an  odor  from  the  mouth  appears,  especially  in  the  morn- 
ing,  immediately   after   the   sleep.     This   odor  differs   from  that 


90  DISEASES   OF  THE   MOUTH 

which  is  the  symptom  of  a  more  serious  inflammation  of  the 
mouth  by  being,  first,  not  repugnant  and  so  faint  that  it  may  be 
distinguished  only  at  a  very  short  distance,  and  secondly,  by  disap- 
pearing for  a  short  time  after  cleansing  the  mouth.  In  some  cases, 
especially  in  children  suffering  from  chronic  indigestion,  the 
tongue  appears  as  if  covered  by  tender,  thin,  but  very  noticeable 
black  hairs,  which  makes  it  dark  brown.  This,  the  so-called  black 
or  hairy  tongue,  has  no  special  diagnostic  value. 

From  Gundobin's  investigations  {Medic.  Ohozrenjc  t.  xxx, 
p.  604),  and  those  of  Brosid  {ibidem,  abstract  p.  612),  it  is  evi- 
dent that  the  old  opinion  alx)ut  the  mycotic  origin  of  the  hairy 
tongue  is  incorrect ;  in  reality  the  threads  consist  exclusively  of 
the  horned  and  darkened  epithelial  cells.  There  was  not  found  in 
the  oral  cavity,  in  lingua  nigra,  any  specific  i)arasite  of  this  lesion. 

[Gundobin's  and  Crosid's  investigations  seem  to  be  confirmed 
by  Beck,  who,  from  the  residts  of  careful  study  of  a  case  of  lingua 
nigra,  came  to  the  conclusion  that  this  morbid  form  is  a  hyper- 
plasia of  the  epithelium,  of  papilhe  filiform?e  which  grow  to  such 
an  extent  as  to  be  nianipulable.  and  wliicli  rcsemljle  wet  hairs.  Tbe 
pathologic  change  is  a  keratinization  of  the  epithelium.  The  color 
is  said  to  be  due  to  the  aged  condition  of  the  epithelium,  and  its 
horny  change — a  constant  decrease  of  the  normally  present  pig- 
ment. In  a  word,  this  disease  is  regarded  as  a  combination  of  h}-- 
perkeratosis  and  pigmentary  growths.  (Illinois  Med.  Journ.,  Jan- 
uary, 1904;  p.  591.) — Against  the  parasitic  theory  are  also  the 
opinions  of  the  majority  of  the  leading  hTench  dermatologists 
(Barthelemy,  Darier,  Gaston  ).as  well  as  the  experimental  bacterio- 
logical investigations  of  Weil  and  Roger,  who  did  not  succeed  in 
producing  lingua  nigra  experimentally  by  inoculation  of  a  fungus, 
which  was  described  by  Ruynaud  and  Lucet  as  the  real  cause  of 
this  disease. (*) — Earle.] 

The  dark,  hairy  tongue  must  not  be  confused  with  the  black 
tongue  due  to  its  occasional  staining  with  food  articles  or  some 
•drugs,  as,  for  instance,  black-berries,  cherries,  iron-preparations, 
etc.,  or  to  the  formation  on  its  surface  of  black-brown  crusts,  as 
in  grave  typhoid. 


^Semaine  Mcdicale,  1903. 


Disi-:.\si-".s  oi--  'iiii-;  Mor-pu  91 

A  simple  catarrh  of  the  mouth  arises  under  the  influence  of 
the  most  variable  causes.  I'or  instance,  in  the  new-born  it  usu- 
ally precedes  the  devel()])ment  of  soor,  later  on  it  often  accom- 
panies dentition,  as  well  as  all  febrile  i)rocesses  and  local  dis- 
eases of  the  fauces,  stomach  and  bowels. 

However,  despite  the  manifold  causes,  a  coated  tongue,  or 
the  way  of  its  clearing-  up,  may  to  some  extent  aid  in  the  diag- 
nosis. 

So,  in  doubtful  cases  of  stomach  catarrh  which  simulate 
meningitis,  a  thickdy-coated  tongue  (felt-tongue)  points  strongly 
to  an  affection  of  the  stomach  and  against  meningitis. 

The  course  of  the  cleaning  up  of  the  tongue  is  of  value 
in  the  diiterential  diagnosis  of  tx'phoid  from  the  first  period  of 
"recurrent  fever.  I"or  the  majority  of  cases  of  moderate  typhoid 
it  is  typical  that  the  tongue  begins  to  clean  up  from  the  margins 
and  the  end  in  such  a  way  that  on  the  anterior  half  of  the  organ 
"there  arises  a  red  triangle  turned  with  its  apex  to  the  base  of 
the  tongue,  while  in  recurrent  fever  the  tongue  (all  the  time) 
remains  moderately  coated. 

In  the  later  stages  of  typhoid  fever  the  tongue  becomes  some- 
what dry;  when  pushed  out  it  looks  narrow,  thick,  sharp-pointed; 
while  in  relapsing  fever  it  is,  in  the  overwhelming  majority  of 
instances,  wet,  wide  and  flat,  with  a  roundish  end. 

Still  more  characteristic  is  the  cleaning  of  the  tongue  in 
scarlet-fever,  and  the  so-called  scarlatinous  tongue  is  well  known. 
During  the  first  two  or  three  days  the  tongue  in  scarlet  fever 
is  usually  quite  coated,  then  it  gradually  begins  to  clean  (first  at 
the  tip  and  margins ) ,  and  after  about  two  days  becomes  entirely 
free  from  the  coating  and  appears  of  an  intense  red-strawberry 
color  with  considerably  enlarged  papillae.  Such  a  tongue  (red, 
with  large  papillae)  is  very  typical  of  scarlet  fever,  because  it 
•occurs  in  well-developed  form  almost  solely  in  this  disease,  and 
may  therefore  decide  the  diagnosis  in  doubtful  cases  of  scarla- 
tina, which  run,  for  instance,  entirely  or  almost  without  any 
eruption,  but  with  sore  throat.  One  should,  however,  bear  in 
mind  that  the  absence  of  the  scarlatinous  tongue  cannot  serve 
as  a  reason  for  excluding  scarlet  fever,  and  that  on  the  first  or 
^ven  the  second  day  of  the  disease  the  character  of  the  tongue  has 


92 


DISEASES   OF  THE   MOUTH 


HO   iiiiportaiicc  in   the  diagnosis  at  all.  because   its  cleaning  upr 
begins  later. 

In  nurslings  fed  exclusively  on  milk,  the  tongue  appears 
white,  because  of  a  thin  layer  of  milk  which  remains  on  its 
rough  surface.  In  some  bottle-fed  children  there  gradually  ac- 
cumulates on  the  tongue  remnants  of  casein  which,  in  their  color 
and  localization,  are  very  similar  to  a  "coated  tongue."  The  dif- 
ference is  that  the  coating  of  a  genuine  "coated  tongue"  cannot 
be  removed  by  the  handle  of  a  spoon,  but  the  coagul?e  of  casein 


Fig.g — Pavement    epitlie  iiim   covered   by   spores   of   the   Oiditmi    All)icans- 
(After  Ch.  Robin). 

are  removed  in  large  pieces,  being  crumbled  like  the  shell  of  an 
egg.  Casein  is  not  difficult  of  recognition  in  the  dry  crusts,  even: 
to  the  unaided  eye. 

Some  similarity  to  a  coated  tongue  may  show  in  a  mycotic 
disease  of  the  mouth  known  under  the  names  of  soor,  or  thrush. 
This  disease  is  characterized  by  the  appearance  of  entirely  white 


DISEASES   OF   THE    MOL'TII 


)  > 


islets  on  the  tong^ue.  the  posterior  surface  of  the  hps.  on  the 
mucous  membrane  of  the  cheeks  and  g:ums,  and,  in  jrravc  cases, 
also  in  the  throat  and  oesophagus. 

The  islets  are.  in  the  beginning-,  firmly  attached  to  the 
mucous  membrane,  but  in  the  period  of  convalescence  they  sepa- 
rate spontaneously.  If  thrush  remains  without  an\-  treatment, 
then  the  separate  islets  (luickly  become  larger,  and  when  coales- 
cent  luay  form  a  continuous  layer,  which  lines  the  whole  surface 
•of  the  mouth,  not  excluding  the  hard  and  soft  palate. 

Among"  the  characteristic   features   of   soor  there   mav  also 


Fig.   10 — Spores  and  branches  of   the  Oidium   Albicans    (Charles   Robin). 

be  included  the  age  of  the  patient,  because  as  a  genuine  disease 
this  occurs  0)ily  in  children  during  the  first  days  of  extra-uterine 
■life,  but  in  older  ones  it  develops  exclusively  during  other  dis- 
eases which  result  in  exhaustion  of  the  organism,  for  instance, 
in  dysentery,  being  in  such  cases  usually  a  symptom  of  imminent 
death.  The  growth  of  the  fungus  {oidium  albicans  of  Robin) 
(Figs.  9  and  lo)  is  favored  by  the  acid  reaction  of  the  oral 
mucus;  therefore  soor  appears  especially  often  in  children  who 
:sufTer  from  dyspepsia  with  acid  eructations  and  in  whom  the  oral 
•cavity  is  kept  unclean. 

A  snow-white  color  of  thrush-spots  is  a  certain  sign  for   in 


94  DISEASES   OF  THE   MOUTH 

easy  differentiation  of  thrush  from  aphthous  inflammation  of  the 
mouth.  In  the  latter  there  also  appears  islets  upon  different 
parts  of  the  mucous  membrane,  but  these  islets,  first,  are  yellow- 
ish, and,  second,  look  like  superficial  ulcerations.  Generally 
speaking,  white  deposits  in  thrush  are  so  characteristic  that  the 
practitioner  will  hardly  ever,  for  diagnostic  purposes,  resort  to- 
the  microscope  in  order  to  find  the  thrush-fungus,  which  consists 
of  long,  twisted  threads,  divided  by  septa,  and  round  spores 
which  intensely  refract  the  light.     (Figs  ii  and  12.) 


Fig.    II — Thrush-fungi    (Lenhartz). 

In  color  and  mode  of  spreading  most  similar  to  tlirush  are 
small  coagulae  of  milk,  which  sometimes  remain  in  the  child's 
mouth  after  nursing,  or  after  regurgitation.  The  dift'erence  is 
that  these  coagulae  may  be  very  easily  removed  by  wiping  the 
mouth ;  in  the  period  of  convalescence  some  of  the  islets  of  thrush, 
may  also  be  easily  removed,  but  never  all  at  once. 

A  thickly-coated  tongue  is  not  easily  confused  with  thrush,, 
because  the  white  coating  in  the  latter  is  never  entirely  limited 
to  the  tongvie,  spreading  also  to  the  other  parts.  The  favorable 
place  of  accimmlation  of  soor-membranes  is  the  inner  surface 
of  the  cheeks. 

For  the  sake  of  completeness  I  also, mention  that  the  white 
spots  or  coats  on  the  oral  mucous  membrane  may  be  obtained 


DISKASES    ()1--    rili-:    MOUTH 


95 


from  cauterization  with  nitrate  of  silver  or  salicylic  acid,  but  tlie 
history  easily  determines  this  ((uestion. 

Markedly  similar  white,  but  tender  and  easily  removable, 
membranes  occur  on  the  oums  durin^-  any  stomatitis.  Their 
orioin  is  due  to  hyperplasia  of  the  epithelium.  From  the  spots 
of  thrush  thev  differ  by  beiu";  easily  removed  ;  it  suffices  there- 
fore to  pass  the  finger  over  the  gums. 

A  peculiar  aspect  of  the  tongue  is  obtained  in  the  annular 
dcsqiiaiiiafion  of  the  cf>lthcliii!ii — pityriasis  liiii^iicv. 

Tn  this  form  of  stomatitis  (probably  also  of  mycotic  origin) 
on  the  upper  surface  of  the  tongue  (the  lower  surface  never  be- 
comes affected)  there  arise  islets  the  size  of  a    pea,  of  pale-rose 


12 — Thrush   fungus:    (a)    niAccliuni  ;    (h)    spores;    (c)    epitheHal  cells 
from  the  mouth  ;   ( d )  leucocytes;   (e)  detritus  (After  Jaksch). 


color  (normal  mucous  membrane),  circumscribed  by  a  whitish 
areola  (hyperplasia  of  the  epithelium).  These  rings  (sometimes 
there  is  only  one)  increase  each  day,  like  the  same  affection 
occurring  on  the  skin  in  psoriasis,  herpes  iris,  etc.,  the  surround- 
ing rings  coalesce  in  their  peripheries,  while  at  the  point  of  their 
union  the  white  areola  disappear,  and  instead  of  rings  there  are 
obtained,  on  the  surface  of  the  tongue,  twisted  lines,  which  well 
define  the  pale-rose,  normal  ])laccs  from  the  neighboring  whitish, 
coated  ones — a  map-like  toiii^ne. 


96  DISEASES   OF  THE   MOUTH 

After  the  lapse  of  a  certain  time  the  tongue  becomes  clear 
over  its  whole  surface  and,  recovering  its  usual  epithelial  layer, 
returns  to  the  normal,  but  seldom  remains  so  very  long,  the 
annular  desquamation  starting  again,  and  in  such  manner  the 
disease  may  last  many  months  without  causing  the  patient  any 
discomfort,  as  there  are  no  pronounced  subjective  symptoms.  It 
is  very  often  met  with  in  children  of  any  age,  in  healthy  as  well 
as  in  ill  ones,  but  especially  often  in  rachitis. 

The  diagnosis  is  not  difficult  even  in  that  stage  when  instead 
of  rings  there  remain  twisted  lines,  because  the  characteristic 
areola  on  the  boundary  of  the  normal  mucous  membrane  of  the 
tongue  cannot  be  confused  with  anything  else.  In  the  first 
period  of  sickness  it  may  be  looked  upon,  perhaps,  as  a  stomatitis 
aphthosa,  but  the  ulcers  are  absent,  as  well  as  the  salivation  and 
pains.  Parrot  was  wrong  in  accepting  pityriasis  linguae  as  a 
symptom  of  inherited  syphilis,  some  sequelae  of  which  have 
really  a  remote  similarity  to  pityriasis  linguae,  especially  from 
a  superficial  examination.  Besides  the  fact  that  in  inherited 
syphilis  it- is  almost  always  possible  to  find  the  characteristic  erup- 
tion on  the  skin,  the  difi^crcnce  is  that  syphilis  never  makes  itself 
evident  on  the  tongue  in  the  form  of  the  above  described  rings, 
but  always  in  the  form  of  jxitches.     (See  page  104.) 

SrOxMATiTis  Moi-iiuLLosA.  Au  affcctiou  of  the  mouth  in 
measles,  in  the  form  of  s])otted  or  papular-spotted  eruption  on 
the  oral  mucous  membrane,  aj^pears  twelve  to  thirty-six  hours 
earlier  than  the  cutaneous  rash,  so  that  it  may  allow  us  to  diag- 
nosticate measles  in  the  prodromal  period ;  therefore,  this  rash 
is  called  prodromal  measles  rash.  It  consists  of  small,  red  spots 
which  first  occupy  the  soft  palate,  but  very  soon  spread  also  over 
the  lips  and  cheeks.  At  the  place  of  the  prodromal  eruption 
there  appears,  on  the  following  day,  desquamation  of  epithelium 
in  the  form  of  very  tender,  whitish  islets,  easily  removable  by 
the  finger,  and  which  make  the  mucous  membrane  look  as  if 
dusted  w'ith  bran.  The  latter  is  best  seen  on  the  inner  surface  of 
the  cheeks,  lips  and  on  the  gums.  This  "bran-like""  appearance 
does  not  occur  in  other  forms  of  stomatitis,  so  that  its  diagnostic 
significance  is  by  no  means  less  than  that  of  the  prodromal  mor- 
billous  rash.  In  some  cases  the  prodromal  eruption  appears 
rather  tardilv,   comins:   on   either   simultaneously   with   the   rash 


DISEASES   OF  THE   MOUTH 


97 


on  the  face,  or  even  still  later,  so  that  the  absence  of  the  erup- 
tion on  the  palate  cannot  prove  that  no  measles  infection  exists. 

[This  peculiarity  was  pointed  out  by  Prof.  N.  Flatov  in  his 
Lectures  on  Acute  Infectious  Diseases  in  Children,  edition  of 
1894-1895;  thus  earlier  than  Koplik  described  his  spots.  Accord- 
ing to  Prof.  Jurgensen,*  Dr.  Flindt,  of  Denmark,  described  very 
minutely  in  the  sixties  of  the  past  century  the  prodromal  measles 
rash  in  the  mouth.  This  rash  becomes  evident  in  the  throat  (soft 
palate  and  tonsils)  on  the  first  day  of  the  fever,  in  the  form  of  a 
rather  diffuse  redness,  which  increases  on  the  second  day  and 
then  consists  of  round,  irregular-shaped,  slightly-elevated  spots. 
The  rash  on  the  third  day  spreads  further  over  the  posterior  two- 
thirds  of  the  hard  palate,  consisting  of  numerous,  confluent,  very 
red  spots.  The  latter  occur  also  on  the  cheeks  and  conjunctivae, 
the  rest  of  the  mucous  membrane  being  normal.  On  the  fourth 
day  the  spots  on  the  hard  palate  and  the  mucous  membrane  of 
the  cheeks  become  still  more  pronouncetl,  those  on  the  cheeks 
appearing  diffuse. 

Filatov's  sign  is  not  less  important  and  characteristic  of 
measles  than  the  so-called  Koplik  sign.  In  1896  Dr.  Koplik,  of 
New  York,  described  some  peculiar,  bluish-white,  slightly  elevated 
spots,  from  two  to  six  millimeters  in  diameter.  These  spots  are 
found  most  constantly  on  the  mucous  membrane  of  the  cheeks, 
but  may  also  be  found  on  the  lips,  and  sometimes  on  the  tongue. 
They  can  be  removed  by  dressing-forceps  without  producing  pain 
or  haemorrhage.  They  never  become  confluent  and  consist  of  an 
accumulation  of  fatty,  degenerated  epithelial  cells.  Their  diag- 
nostic importance  lies  in  their  appearing  usually  on  the  first  or 
second  day  of  the  prodromal  period  and  increasing  in  number 
during  the  subsequent  six  or  seven  days. 

Koplik's  observations  are  generally  confirmed  in  America,  as 
well  as  in  Europe,  although  lately  some  authors,  Aronheim,  for 
instance,  are  inclined  to  regard  Koplik's  sign  as  not  an  absolutely 
constant  and  certain  one  of  measles,  because  during  an  epidemic 
of  this  disease  he  met  Koplik's  sign  only  in  six  per  cent.  (Of 
150  cases  only  nine  proved  positive.) — Earle.] 

*Nothnagcl's  Encyclop.,  Vo!.  IV.,  P.  II.,  p.  92,  93,  1896. 
*Aronheim:   Sind  die  Koplik'shen  F!ecken  ein  sicheres   Friihsymptom 
der  Masern?     (Miiiich.  Medic.  IVoch.  N.  28,  14  July.  i903-) 


98  ,  DISEASES    OF  THE   MOUTH 

f  Comedones  palati  duri.  In  the  nevv-boni  and  in  children 
of  the  first  weeks  of  Hfe,  one  may  ahnost  always  see  on  the  hard 
palate  congenital  formations  known  as  Bohii's  nodules.  They 
have  the  aspect  of  small  (not  larger  than  a  pin's  head),  entirely 
white,  conical  elevations,  located  in  groups,  several  nodules  in 
each,  in  the  middle  of  the  hard  palate,  along  the  sutures.  These 
nodules  are  of  diagnostic  value  only  when  they  occur  on  the 
gums  of  children  several  months  old,  and  thus  simulate  teething. 
A  distinction  is  made,  first,  by  the  fact  that  these  formations 
remain  long  on  the  same  place  and  then  disappear  without 
leaving  any  trace ;  secondly,  being  semi-solid,  they  do  not  give,  on 
percussion  with  some  metal,  that  characteristic  sound  which  is 
obtained  by  percussing  a  coming  tooth. 

Dentition.  In  close  connection  with  the  diseases  of  the 
mouth  is  dentition,  regarding  which  it  would  be  suitable  to  here 
say  a  few  words. 

The  first  dentition  in  children  begins  at  different  times,  de- 
pending upon  the  hereditary  disjiosition,  condition  of  the  general 
nutrition  of  the  organism  and  upon  different  diseases.  The  aver- 
age time  for  the  beginning  of  dentition  may  be  accepted  as  the 
seventh  or  eighth  month,  at  which  period  the  two  inferior  middle 
incisors  appear,  later  (ninth  or  tenth  month)  the  four  upper  in- 
cisors, so  that  toward  the  end  of  the  year  a  healthy  child  should 
have  all  incisors  (eight  teeth).  Then  the  intervals  become  longer 
(about  two  months),  and  from  the  fourteenth  up  to  the  sixteenth 
month  the  first  molars  appear,  from  the  eighteenth  up  to  the 
twentieth  the  canines,  from  the  twenty-second  up  to  the  twenty- 
fourth  the  second  molars,  when  the  cutting  of  the  milk-teeth 
is  ended. 

The  first  teeth  are  sometimes  cut  several  months  earlier 
than  the  normal  term  mentioned,  for  instance,  in  the  fourth  or 
fifth  month,  but  sueli  a  premature  appearance  of  the  teeth  is  of 
no  special  importance.  In  the  majority  of  such  cases  the  subse- 
quent groups  are  cut  in  the  normal  term,  so  that  toward  the 
end  of  the  year  such  children  have  no  more  than  seven  or  ten 
teeth.  Too  short  intervals,  depending  upon  the  abnormally  in- 
creased nutrition  of  the  embryonal  teeth,  between  the  separate 
eroups,  is  sometimes  observed  in  children  prone  to  active  hyper- 
aemia  of  the  head,  and  frec|uently  terminates  with  acute  hvdro- 


DISEASKS    OF   THE   MOUTH  gtj 

cephalus,  so  that  the  too  rapid  appearance  of  the  teeth  mav  be 
looked  upon  somewhat  as  an  unfavorable  omen. 

Retarded  dentition  means  that  either  only  the  first  ^roup  ap- 
pears too  late,  all  those  following  coming  at  the  proper  time, 
or  that  the  intervals  are  too  long,  so  that  dentition  occurs  too 
slowly,  being  protracted  until  the  end  of  the  third  or  fourth  year. 

In  the  former  event,  that  is,  when  the  initial  group  does  not 
duly  erupt,  the  order  of  appearance  of  the  groups  remaining  nor- 
mal, then  the  late  dentition  is  of  no  pathological  value,  as  such  a 
retardation  is  observed  not  infrequently  in  healthy  children,  esj)e- 
cially  when  there  is  some  family  predisposition,  where  a  similar 
anomaly  occurs,  for  instance,  in  all  or  in  the  majority  of  brothers 
and  sisters  of  the  same  household.  It  is  entirel}'  dilterent  when 
long  intervals  pass  between  the  eruption  of  separate  teeth,  or 
when  groups  are  erupted  simultaneously.  Such  an  irregularity 
is  indicative  of  a  retarded  process  of  ossification  of  the  skeleton, 
and  is  usually  peculiar  to  rachitis. 

With  regard  to  the  question  whether  dentition  may  influence 
the  child's  health,  the  author's  opinions  do  not  agree  altogether 
with  others.  Some  exaggerate  the  importance  of  this  physio- 
logical process  in  the  aetiology  of  disCfises,  others,  on  the  contrary, 
deny  it  completely.  In  my  opinion  it  is  impossible  to  deny  the 
existence  of  some  connection  between  dentition  and  some 
diseases  of  childhood,  but  in  each  case  one  must  be  very 
cautious  not  to  overlook  any  other  cause.  The  dependence  of 
a  disease  upon  teething  may  be  suspected  only  when  the  disease 
begins  shortly  before  the  appearance  of  the  tooth,  when  the  cor- 
responding place  of  the  gum  becomes  szvoUen,  tense,  and  when 
the  appearance  of  the  tooth  causes  the  disease  to  disappear. 

The  physician  has  still  more  reason  to  suspect  a  causative 
relation  between  dentition  and  a  disease  if  the  same  morbid  ap- 
pearance be  repeated  at  each  "teething,"  and  when  it  is  impossible 
to  detect  another  cause  of  the  given  sickness. 

If  we  are  to  be  guided  in  the  diagnosis  of  "teething-dis- 
eases" by  the  criteria  just  given,  then  it  is  evident  that  a  depend- 
ence of  diseases  upon  teething  is  not  often  met  with,  and  that 
such  diseases  are  neither  grave,  nor  so  frequent  as  commonly  be- 
lieved. 

Teething  is  in  many  cases  accomplished  entirely  inipercep- 


lOO  DISEASES   OF  THE   MOUTH 

tiblv.  being  recognized  only  when  the  top  of  the  tooth  appears. 
In  other  cases,  especially  when  the  thick  crown  of  the  molar  is 
cut.  a  catarrhal  or  aphthous  stomatitis,  accompanied  with  fever, 
irritability,  sleeplessness,  etc.,  sets  in  several  days  before  the 
appearance  of  the  tooth.  That  stomatitis  depends  in  such  cases 
upon  teething,  but  not  upon  any  other  cause,  one  may  conclude 
from  the  inflammation  being  mostly  developed  on  that  part  of  the 
gum  where  the  tooth  is  cut. 

Mothers  often  ask  the  physician  if  the  child  is  teething,  and 
point  out  that  he  is  suffering  from  a  constant  salivation  and  that 
he  puts  his  fingers  into  the  mouth.  The  mother  becomes  com- 
pletely convinced  if  she  notes,  somewhere  on  the  gum,  Bohn's 
nodule. 

In  deciding  such  questions  one  should  bear  in  mind  that  sali- 
vation in  children  two  or  three  months  of  age  is  a  physiological 
occurrence,  because,  in  this  age,  begins  the  increased  activity  of 
the  salivary  glands,  v.'hich  during  the  first  few  months  of  life 
are  almost  inactive.  The  mistake  is  easily  avoided  if  attention 
be  directed  to  the  child's  age  and  to  the  absence  of  signs  of  local 
irritation  of  the  gums. 

Teething  may  further  produce  a  slight  disorder  of  digestion, 
in  the  form  of  frequent  vomiting  and  varied  dejecta  as  well.  Such 
a  disorder  usually  docs  not  last  very  long,  is  associated  with 
apparent  symptoms  of  irritation  of  the  gums  due  to  dentition, 
while  it  disappears  soon  after  the  eruption  of  the  tooth,  often 
reappearing  in  the  following  teething,  while  no  definite  cause  of 
the  disorder  may  be  found. 

Whether  eclamptic  convulsions  may  be  produced  by  dentition, 
is  a  disputable  question. 

It  rarely  happens  that  perfectly  healthy  children  suft'er  from 
convulsions  during  dentition  only,  and  that  they  recur  with  each 
teething  group ;  but,  on  the  other  hand,  it  is  undoubtedly  true, 
that  dentition  may  be  an  occasional  provocation  of  reflex  con- 
vulsions in  such  children  as  are  predisposed  to  them,  as.  for  in- 
stance, in  rachitic  ones.  It  is  evident,  however,  that  in  diag- 
nosticating "teething  convulsions"  the  conditions  mentioned  on 
page  99  must  always  be  present. 

For  alteration  in  the  shape  of  the  teeth  the  reader  is  re- 
ferred to  part  on  Syphilis. 


DISEASES   OF   THE    ]\r()rTll  10  [ 

DISEASES  OF  THE  MOUTH  OCCURRING  WITH  THE 
FORMATION  OF  ULCERATIONS  UPON  THE  MU- 
COUS MEMBRANE,  BUT  WITHOUT  OFFENSIVE 
ODOR. 

Especially  peculiar  to  childhood  is  one  form  of  ulcerous  in- 
flammation of  the  lips,  which  was  described  by  Sevestre  under 
the  name  of  staphylococcus  diphtheroid  stomatitis  (stomatite  diph- 
theroide  a  staphylocoques).*  The  morbid  process  is  localized 
mostly  (and  sometimes  exclusively)  on  the  inner  surface  of  the 
lips,  often  travelling  over  the  inner  surface  of  the  cheeks.  The 
affected  parts,  especially  the  lips,  are  covered  with  a  yellowish 
exudation,  which  looks  like  a  diphtheritic  patch.  The  lips  soon 
become  covered  with  black,  bloody  crusts  because  of  the  forma- 
tion of  bleeding  fissures. 

The  morbid  process  never  extends  over  the  gums,  but  some- 
times occupies  the  cheeks  and  the  tongue.  After  a  few  days 
the  exudation  begins  to  disappear  gradually,  and  the  superficial 
ulceration  of  the  lips  heals  in  from  seven  to  fourteen  days,  with- 
out any  scar.  Simultaneously  with  the  affection  of  the  lips,  there 
is  frequently  noticed  an  impetiginous,  eruption  on  the  face.  The 
disease  differs  from  diphtheria  by  its  benign  course,  non-conta- 
giousness and  absence  of  LotHer's  bacillus.  Sevestre  found  the 
staphylococcus  aureus  in  the  exudation  taken  from  the  mucous 
membrane,  as  well  as  in  the  pus  of  impetiginous  pustules ;  so 
that  this  morbid  form  may  be  called  stomatitis  impcfigiiwsa. 

Staphylococcus  stomatitis  which  often  occurs  in  the  nezv-born 
of  the  foundling  hospitals,  and  which  occurs  with  simultaneous 
lesion  of  the  soft  palate,  fauces  and  other  parts  of  the  mucous 
membrane,  was  described  by  Epstein  as  septic  stomatitis.  In 
Epstein's  opinion  such  stomatites  give  rise  to  the  development 
of  general  sepsis  in  the  new-born. 

Of  much  more  frequent  occurrence  is  aphthous  infla^[- 
MATiON  OF  THE  MOUTH — stomatltis  aphthosa.  This  disease  is  char- 
acterized by  the  occurrence  on  the  mucous  membrane  of  the 
tongue,  lips  and  cheeks  of  round,  superficial  ulcers,  from  the  size  of 
a  pin's  head  up  to  that  of  a  lentil,  covered  with  yellowing  exuda- 
tion and  circumscribed  bv  a  red  areola.    This  maladv  is  most  often 


*Rcziue  mens,  des  )miladies  des  enfcints,  iiSg2,  page  47. 


102  DISEASES   OF  THE   MOUTH 

met  with  in  children  about  the  time  of  the  first  teething.  The 
causes  of  this  disease  are  unknown   (infection?). 

[Regarding  the  etiology  of  this  form  of  stomatitis  it  will 
be  interesting  to  refer  to  Brush's  observations  of  an  epidemic  of 
foot-and-mouth  disease  among  the  cattle  in  New  England. 
Brush  *  says  that  there  is  undoubtedly  some  relation  between 
aphthae  of  the  mouth  in  the  human  young  and  foot-and-mouth 
disease  in  cattle,  and  that  we  may  distinguish  two  forms  of  aph- 
thous stomatitis,  viz:  contagious  (i.  e..  due  to  foot-and-mouth 
disease  of  cattle)  and  non-contagious.  The  diagnosis  between 
these  two  forms  may  be  determined  by  the  treatment,  that  is, 
the  severer  variety  caused  by  an  infected  milk  rapidly  subsides 
as  soon  as  the  milk  is  stopped. — Earle.  | 

An  unclean  condition  of  the  mouth,  mentioned  in  the  text- 
books as  an  ^etiological  factor,  does  not  play  a  very  important 
role. 

These  ulcerations  are  either  found  in  small  groups  (one  to 
six),  or  are  thickly-crowded,  so  that  some  coalesce,  forming  larger 
ulcerations  of  irregular  outline,  but  always  superficial  and  of  yel- 
lowish tint.  The  formation  of  ulcers  is  always  accompanied  by 
considerable  painfulness  (especially  when  using  hot  drinks,  -as 
well  as  salted,  sweet  and  hard  food),  salivation  and  intensely 
coated  tongue. 

Aphthous  stomatitis  has  either  a  subacute  course,  without 
fever,  or  an  acute  one  with  fever,  the  temperature  rising  fre- 
quently to  forty  degrees  C.  (104  degrees  F.)  and  higher,  and  in 
small  children  (under  two  years  of  age)  convulsions  may  also 
occur.  In  such  cases  the  eruption  of  aphthae  does  not  occur  at 
the  very  first  (signifying  that  the  stomatitis  does  not  produce 
fever),  but  only  on  the  second  or  third  day  after  the  elevation  of 
temperature.  This  fact,  in  connection  with  the  additional  one 
that  sometimes  several  members  of  the  same  family  become 
affected  one  after  the  other,  is  indicative  of  the  infectious  nature 
of  the  disease, — something  similar  occurring  in  the  eruption  of 
herpes  on  the  lips  (fievre  herpetique,  of  the  French  authors.) 
The  similarity,  and  perhaps  the  identity,  of  these  diseases,  i.  e., 
of  the  acute  febrile  form  of  aphthous  stomatitis  and  herpes  of 
the  lips,  appear  also  in  the  aphthae.     These  are  sometimes  met 

*Jouni.  Amcr.  Med.  Assn..  June- 20,  1903,  pp.  1700-1704. 


DISEASES   OF   THE    MOUTH  IO3 

with  on  the  tongue,  or  on  other  parts  of  the  mucous  membrane  of 
the  mouth,  in  groups  which  consist  of  several  thickly-coated, 
round  ulcers.  Such  a  form  of  stomatitis  is  sometimes  described 
under  the  name  of  herpetic  iiiHaiiimafioii  of  the  mouth — stomatitis 
hcrpetica. 

In  other  cases  aphthous  inflammation  of  the  mouth  seems  to 
depend  upon  stomach  disorders  or  on  dentition  (especially  of  the 
molars).  This  disease  always  terminates  in  rapid  recovery  with- 
out disagreeable  consequences,  by  wdiich  it  differs  from  the  other 
form  of  ulcerous  stomatitis — the  so-called  stomacace. 

Aphthous  ulcers  are  by  themselves  so  characteristic  that  it 
is  difficult  to  confound  stomatitis  aphthosa  with  anything  else, 
except,  perhaps,  with  foot-and-mouth  disease  (aphthae  epizoot- 
icae),  of  which  I  shall  speak  later  on.  (About  differentiation 
from  soor  see  page  94;  from  stomacace,  see  page  105.) 

Somewhat  similar  to  aphth?e  is  ivricelloiis  stomatitis  (stom- 
atitis varicellosa ) .  wdiich  is  characterized  by  the  eruption  of 
vesicles,  the  size  of  a  pin's  head,  on  the  hard  and  soft  palates,  and 
partly  also  at  other  points.  These  vesicles  seldom  become  con- 
verted into  ulcers.  Their  character  is  easily  determined  by  the 
presence  of  the  varicella  eruption  on  the  skin. 

From  aphthous  stomatitis  one  must  distinguish  another  af- 
fection of  the  mouth,  which,  notwithstanding  the  name,  has  noth- 
ing to  do  with  this  tlisease.  We  refer  to  the  so-called  aphthcc  of 
the  nezv-born,  or  Bednar's  aphthcc.  This  disease  is  peculiar  only 
to  children  from  two  days  to  six  weeks  of  age,  and  is  indicated 
by  the  appearance  of  two  symmetrically-located  (in  the  angles 
of  the  palate,  in  the  portero-external  corner  of  the  horizontal 
part  of  the  palate  bone),  round,  superficial,  grayish-yellow  ulcera- 
tions occupying  exactly  that  spot  on  the  mucous  membrane  where 
the  latter  is  supported  by  one  of  the  processes  of  the  sphenoid 
bone  (hamulus  pterygoideus).  The  ulcers  disappear  without 
local  damage,  in  the  great  majority  of  cases,  in  from  one  to  three 
weeks,  but  in  the  presence  of  poor  hygienic  conditions  and  in 
marantic  children  these  small  ulcers  spread  over  the  surface,  as 
well  as  in  depth  ;  they  then  coalesce  with  each  other,  form  deep 
ulcers,  reach  the  bone,  occupying  the  whole  soft  palate, 
so  that  they  may  simulate  diphtheria.  The  chief  points  in  the 
diagnosis  are,  first,  the  classical  location  of  the  ulcerations ;  sec- 


I04  DISEASES   OF  THE   MOUTH 

end,  the  ag-e  of  the  patient,  and,  third,  a  febrile  course  (only  if 
there  are  no  other  causes  for  the  elevation  of  temperature). 

The  cause  of  the  ulcers  is  a  mechanical  one.  viz  :  friction  and 
pressure  by  the  base  of  the  tongue,  during  the  act  of  sucking, 
upon  the  prominent  point  of  the  pterygoid  process. 

To  the  diseases  of  the  mouth  which  may  determine  the  diag- 
nosis of  a  general  disease  belongs  also  ulceration  of  the  frenulum 
of  the  tongue  and  syphilitic  stomatitis. 

Ulceration  of  the  frenulum  linguae  is  a  characteristic  symp- 
tom of  whooping-cough,  the  ulceration  arising  because  of  the 
frenulum  being  cut  or  torn  by  the  inferior  incisors  during  the 
violent  attacks  of  coughing.  The  ulceration  resembles  a  per- 
fectly white  membrane,  the  size  of  a  lentil,  located  just  on  the 
frenulum.  It  almost  never  occurs  in  children  having  no  inferior 
incisors.  The  diagnostic  meaning  of  this  ulceration  is  typical, 
inasnuich  as  it  is  encountered  almost  exclusively  in  |)ertussis. 

Sni'IIII.itk'  sroMATiris  is  observed  in  syphilitic  children  very 
often,  especially  in  the  relapses.  This  malady  is  indicated  by 
the  a])pearance  of  whitish,  slightly-elevated  ])atchcs  (condylo- 
mata) on  the  nnicous  membrane  of  the  mouth,  especially  on  the 
inner  surface  of  the  cheeks  near  the  angles  of  the  mouth,  as  well 
as  on  the  lips,  tongue,  soft  palate  and  tonsils.  These  patches 
differ  from  all  other  formations  occurring  in  this  part  by  their 
papillar  structure,  so  that  one  may  sometimes  succeed  in  seeing 
on  the  surface,  even  with  the  naked  eye,  the  numerous,  very 
thickl\-  crowded  tops  of  papill;v  in  the  form  of  whitish-gray 
spots. 

Less  distinctive  of  syphilis  are  fissures  of  the  lips  and  of  the 
corners  of  the  mouth.  These  symptoms  have  comparativel} 
greater  diagnostic  value  in  inherited  syphilis  in  children  during 
the  first  weeks  of  life.  In  children,  however,  of  more  advanced 
age,  fissures  of  the  lips  occur  also  in  the  absence  of  syphilis,  for 
instance,  under  the  influence  of  fever.  Such  fissures  sometimes 
become  developed  into  very  painful  ulcers.  In  other  cases  the 
cause  of  the  ulcerations  of  the  lips  is  the  tendency  of  children 
to  tear  ofi  pieces  of  cuticle  from  the  drying  lips. 

In  conclusion  we  may  also  refer  to  bitten  zvourids  of  the 
foiii^^iie,  caused  by  the  patients  themselves  either  during  an  epi- 
lei)tic  spell  or  other  attacks  of  an  entirely  diiTerent  nature,  in  the 


DISEASKS    OF   THE    MOUTH  '  105 

diagnosis  of  which  these  wounds  may  be  of  vahie  when  the  his- 
tory is  insufficient. 

DISEASES  OF  THE  MOUTH,  ACCOMPANIED  BY  THE 
FORMATION  OF  ULCERATIONS  ON  THE  MUCOUS 
MEMBRANE  AND  AN  OFFENSIVE  ODOR. 

The  mouth  is  not  always  the  only  cause  of  stench.  The 
■source  of  the  foetor  may  be  : — 

(i)  Foetid  rhinitis  (stench  is  most  noticed  with  expiration 
through  the  nose,  while  the  mouth  is  closed,  being  almost  absent 
during  the  expiration  through  the  mouth,  when  the  nostrils  are 
•compressed). 

(2)  Stomach-catarrh  with  fcetid  eructation. 

(3)  Bronchiectasis    with    foetid    contents;    and    especially 

(4)  Gangrene  of  the  lungs. 

A  not  very  intense  foetor,  easily  removable  by  a  common 
•cleansing  of  the  mouth,  occurs  with  any  thickly-coated  tongue,  in 
various  catarrhs  of  the  oral  cavity,  especially  during  febrile  pro- 
•cesses,  likewise  in  carious  teeth  and  from  decomposition  of  meat 
food  remaining  between  the  teeth.  But  in  all  these  cases  such 
a  stench  as  associated  with  a  more  serious  affection  of  the  mouth 
never  takes  place. 

FoiTID   INFLAMMATION    OF  THE   MOUTH StOHUlCace,   S.    StOlll- 

-atitis  ulcerosa.  This  disease  of  the  mouth,  depending  upon  gen- 
-eral  malnutrition,  is  characterized,  first,  by  an  intense  odor  from 
the  mouth  ;  second,  by  an  ulcerous  process  which  always  begins 
at  the  free  margin  of  the  gums,  of  the  incisors  or  canines,  and 
then  extends  over  the  gums  of  the  other  teeth  ;  and  third,  by 
never  occurring  in  toothless  children.  Fourth,  there  is  also  a 
characteristic  alteration  of  the  gums,  which  become  swollen,  fri- 
able, intensely  hypenemic,  and  easily  bleed  upon  the  slightest 
touch. 

This  form  decidedly  differs  from  aphthous  stomatitis,  first, 
in  the  shape  of  the  ulcers  (in  the  latter,  small  round  ulcers 
spread  all  over  the  mucous  membrane  of  the  mouth  :  in  the  former, 
ulcerative  destruction  of  the  iiiari^iu  of  swollen  and  easily-bleed- 
ing gums )  ;  second,  by  violent  stench  from  the  mouth ;  and,  third, 
by  its  prolonged  course. 

In  neglected  cases  the  destruction  of  the  gums,  accompruiied 


I06  DISEASES   OF  THE   MOUTH 

by  falling  out  of  the  teeth,  may  even  lead  to  necrosis  of  the 
jaw.  On  the  other  hand,  the  ulcerative  process,  because  of  auto- 
infection,  readily  spreads  from  the  gums  to  the  adjacent  mucous- 
membrane  of  the  cheek,  so  that  after  about  two  weeks  from  the 
beginning  of  the  disease  there  appears  on  the  cheek  a  mark  of 
the  gums  in  the  form  of  a  double  ulcerous  strip  of  yellowish  tint, 
due  to  the  characteristic  tendency  of  the  ulcers  in  stomacace  to- 
spread,  not  so  much  over  the  surface  as  in  depth  (different  from 
diphtheria).  The  original  superficial  ulceration  of  the  cheeks 
assumes,  after  a  few  days,  the  aspect  of  deep  ulcers,  the  floor  and 
the  margins  of  which  are  covered  with  a  dirty-yellow  deposit. 
The  whole  cheek  becomes  swollen  (ciedematous).  the  submaxillary 
glands  enlarged,  but  the  skin  of  the  swollen  cheek  remains  pale. 
Fever  may  be  entirely  absent,  but  if  the  temperature  rises  it  is 
only  in  the  beginning  of  the  disease,  and  does  not  reach  a  high 
degree  (38  degrees  to  39  degrees  C. — 100.4  degrees  to  102.2  de- 
grees F.). 

The  further  difl^erentiation  of  stomacace  from  aphthous  stom- 
atitis consists  in  the  relation  of  both  these  diseases  to  the  action 
of  potassium  chlorate  (potassium  oxymuriaticum  s.  chloricum),. 
which  is  specific  only  for  stomacace,  being  quite  indifferent  in 
aphthje. 

In  view  of  these  symptoms  the  diagnosis  of  typical  cases^ 
of  stomacace  is  always  easy.  Difficulty  may  occur  only  when  stom- 
acace becomes  complicated  with  aphthae,  which  complication  oc- 
curs quite  often.  Then  we  have,  simultaneously  with  the  symp- 
toms of  the  former  { foetor  from  the  mouth,  ulceration  and  bleed- 
ing from  the  gums),  also  numerous  round,  yellowish  ulcers  on 
the  tongue  and  neighboring  parts.  In  such  cases  stomacace  is 
of  more  importance,  being  a  graver  process. 

Foetid  inflammation  of  the  mouth,  caused  by  the  immoderate 
use  of  n^Qvcury—stomatifis  incrciirlalis  {  which  occurs  also  in  small 
children  during  calomel  treatment)  differs  from  stomacace  by 
having  a  certain  ^etiological  factor.  \\'e  have  the  same  to  say 
regarding  scorbutic  stomatitis,  which,  however,  is  seldom  met 
with  in  childhood. 

Of  other  causes  of  stomacace  the  most  important  are  to  be 
sought  in  the  general  malnutrition  of  the  organism,  depending 
either  upon  bad  hygienic  conditions,  or  upon  acute  infectious  dis- 


DISEASES   (IF   THE    MOUTH  IO7 

eases.  Therefore,  fcetid  inflammation  of  the  mouth  occurs 
oftener  in  poor  famiHes  in  damp  dwelHngs. 

[This  disease  is  a  contagious  one,  its  contagiousness  having 
been  very  well  illustrated  by  Bierens  de  Haan,  *  who  described 
an  epidemic  of  ulcerative  stomatitis  among  the  Boer  troops  dufr 
ing  the  South  African  war.  The  infection  spread  rapidly  from 
one  person  to  another,  sparing  those,  however,  who  did  not  come 
into  immediate  contact  with  victims  of  the  disease  (for  instance, 
the  Kaffirs).  Haan  thinks  that  the  epidemic  was  largely  due 
to  lack  of  salt  in  the  diet,  inasmuch  as  it  began  to  disappear  as 
soon  as  a  proper  supply  of  this  substance  was  obtained. — Earle.] 

With  relation  to  acute  disease,  stomacace  readily  appears 
after  measles  and  typhoid. 

The  course  of  the  disease,  left  without  any  treatment,  is  very 
uncertain  ;  it  may  last  for  weeks  and  cause  a  loss  of  all  teeth, 
but  when  properly  treated  usually  ends  in  a  few  days,  so  that 
the  prognosis  in  recent  cases  is  generally  good,  but  when  neglected 
a  fatal  termination  may  take  place  because  of  the  subsequent 
development  of  noma,  or  because  of  septico-pyaemia. 

In  the  period  of  ulceration  and  swelling  of  the  cheek  the  clin- 
ical picture  of  stomacace  is  very  similar  to  that  of  noma,  or  water- 
cancer  of  the  check,  cancer  aquaticus.  In  the  beginning  of  the 
disease  there  always  appears  a  tumor  of  the  cheek,  the  integument 
being  pale,  not  hot,  and  painless  upon  pressure ;  then  follows 
ulceration  of  the  mucous  membrane  and  a  very  violent  odor  from 
the  mouth.  The  similarity  to  stomacace  is  still  greater  in  that  in 
both  cases  the  lymphatic  submaxillary  glands  become  swollen,  but 
fever  is  often  absent ;  both  stomacace  and  noma  arise  in  emaci- 
ated children  ;  finally,  the  relationship  of  these  two  diseases  man- 
ifests itself  in  that  stomacace  sometimes  degenerates  into  noma, 
the  latter,  however,  in  its  turn,  very  seldom  develops  spontane- 
ously, but  usually  from  stomacace. 

[Walsh,  in  eight  cases  of  noma,  found  four  that  began  with 
stomacace.** — Eakle.  ] 

Nevertheless  it  is  not  difficult  to  recognize  noma.  The  diag- 
nosis is  based  upon  the  aspect  of  the  affected  parts,  on  the  rapidity 


*Dcut.  Med.  Wochenschr.,  Febr.  12,  1903. 
**Proceed.  Phila.  Path.  Soc,  June,  1901. 


io8 


DISEASES   OF  THE   MOUTH 


of  the  course,  and  the  issues.  The  morbid  process  of  noma  does 
not  consist  in  the  ulceration  of  the  mucous  membrane  of  the 
cheek,  but  in  gangrene,  so  that  the  affected  part  does  not  assume 
a  yellow  tint,  but  a  brown  or  black  one  with  a  gangrenous  odor. 
The  destruction  of  the  cheek,  and  of  the  surrounding  soft  parts, 
is  effected  quicker  than  in  stomacace,  because  gangrenous  perfora- 
tion of  the  cheek  may  take  place  in  three  or  four  days,  and  later 
on  the  gangrene  spreads  daily  farther  and  farther,  so  that  in  a 
few  days  all  soft  parts  of  the  cheek  disappear,  provided  death. 


Fig-   13 — Gangrenous  stomatitis,  following  measles    (After  Holt). 

the  common  although  not  the  certain  termination  of  noma,  does 
not  stop  such  a  destruction.     (Figs.  13  and  14.) 

Noma  sometimes  begins  with  the  skin  of  the  cheek.  In 
such  "a  case  it  could  be  easily  confounded  with  anthrax.  The  lat- 
ter starts  with  the  formation  of  a  small  pustule,  which  is  soon 
transformed  into  a  solid,  odorless  scab  surrounded  by  an  areola 
of  new  vesicles,  and  only  then  there  appears  a  tumor  of  the  soft 
parts.  The  process  spreads  rapidly,  but  does  not  lead  to  perfora- 
tion of  the  cheek,  as  in  noma. 


DISEASES   OF   THE    MOUTH 


109 


Somewhat  equally  between  aphthous  stomatitis  and  stomacace 
occurs  FOOT-AND-MOUTii  DISEASE  (aplitlicc  cpizooticcc) ,  notable  in 
children  after  using"  raw  milk  of  cows  sufifering  from  foot-and- 
mouth  disease. 

This  disease  in  children  is  characterized  by  the  eruption  of 
vesicles,  with  turbid  contents,  on  the  mucous  membrane  of  the 
cheeks,  lips  and  soft  palate;  the  temperature  is  elevated  (39  de- 
grees to  40  degrees  C. — 102  degrees  to  104  degrees  F.).     The 


Fig.  14 — Noma  with  the  affection  of  both  lips,  cheeks,  a'ae  nasi,  eye-lids, 
skin  of  the  forehead  and  temples,  gums,  tonsils  and  pharynx  (Albert). 

spots  differ  from  aphthae  by  usually  being  absent  from  the  dor- 
sum of  the  tongue,  the  posterior  wall  of  the  pharynx  and  tonsils. 
After  the  disappearance  of  the  vesicles  no  ulcers  remain,  but 
there  is  always  a  disagreeable  odor  from  the  mouth,  salivation  and 
intense  rhinitis.  Frequently  there  occur  pains  in  the  abdomen, 
diarrhoea,  and  sometimes  vomiting.  The  disease  lasts  one  to 
two  weeks. 

In    diagnosticating    foot-and-mouth    disease    from    aphthous 
stomatitis  especial  attention  should  be  given  to  the  presence  of 


no  DISEASES   OF  THE    MOUTH 

vesicles,  their  absence  on  the  dorsum  of  the  tongue,  the  odor 
from  the  mouth  and  to  the  violent  snuffles.  The  diagnosis  is 
still  easier  in  cases  in  which  epizootic  aphthae  are  accompanied 
by  the  vesicular  eruption  on  the  skin,  as  the  same  seldom  occupies 
the  whole  body,  is  most  often  located  near  the  nails  of  both  the 
fingers  and  toes,  and  has  the  aspect  of  small  (the  size  of  a  pea) 
vesicles  with  clear  contents. 

In  Weissenberg's  cases  *  itching  and  severe  thirst  were 
also  observed.  The  vesicles  appeared  in  the  mouth,  after  the 
three  days'  duration  of  the  prodromal  fever,  when  the  tempera- 
ture fell  to  normal.  An  extensive  epidemic  of  foot-and-mouth 
disease  was  observed  by  Siegel.  During  one  month  more  than 
two-thirds  of  the  inhabitants  of  a  small  town  became  ill  from  this 
disease.  The  prodromal  fever  lasted  from  three  to  eight  days, 
then  an  inflammation  of  the  mouth  developed  in  the  form  of 
swelling  of  the  tongue,  which  was  covered  with  a  thick,  black 
coating;  then  considerable  swelling  and  friability  of  the  gums 
with  falling  out  of  the  teeth  and  a  very  severe  odor  from  the 
mouth ;  the  lips  and  the  angles  of  the  mouth  were  ulcerated.  The 
patients  complained  of  pain  in  the  ears  and  the  masseters.  On 
the  skin  there  frequently  a])peared  a  rash  with  small  petechicC. 

The  disease  always  had  a  prolonged  course,  of  one  to  one  and 
a  half  years,  because  of  relapses.  Among  the  complications  were 
haemorrhage  from  the  stomach,  pneumonia,  endocarditis,  painful 
swelling  of  the  liver,  vast  haemorrhages  under  the  skin,  in  the 
muscles  and  even  in  the  cavity  of  the  skull,  orchitis  and  album- 
inuria. Siegel  cultivated  a  microbe  from  organs  taken  from 
the  dead  ;  the  inoculation  of  this  microbe  into  cows  produced  in 
them   foot-and-mouth   disease    (aphthae   epizooticas). 

Generally  speaking,  foot-and-mouth  disease  is  seldom  met 
with  in  childhood  and  further  observations  are  therefore  desirable. 

As  I  pointed  out,  stomacace  never  occurs  in  toothless  chil- 
dren, but  in  the  pre-dentition  age  a  similar  morbid  process  occurs, 
described  first  by  KHmentovsky  in  the  Medical  Report  of  the 
Foundling  Hospital  of  Moscow,  1876,  under  the  name  of  Osteo- 
gingk'itis  gangrcrnosa  neonatorum.  (The  last  epithet  is  not  suf- 
ficiently specific,  because  of  his  six  patients  only  one  was  six  days 


*Jahrb.  f.  Kinderh.^  32  S.,   1890. 


DISEASES    OE   THE    MOUTH  III 

of  aj,'e,  and  in  two  other  cases  the  malady  began  on  the  39th  and 
54th  days.)  Osteogingivitis  of  the  new-born  starts  as  a  Hmited, 
inflammatory  swelUng  of  the  gum,  which  very  soon  becomes 
g-angrenous  at  the  point  of  attack  and  from  the  thus-formed 
ulcer  the  crown  of  a  milk-tooth  falls  out  after  two  or  three  days. 
This  morbid  form  is  accompanied  by  fever  and  collapse ;  if  the 
patient  survives  the  first  days  of  the  disease,  then  the  malignant 
suppuration  spreads  over  the  jaw.  producing  caries  of  the  bone. 
In  Klimentovsky's  cases  death  occurred  on  the  fifth  and  the  forty- 
fifth  day  of  the  disease. 

In  Klimentovsky's  opinion,  osteogingivitis  dififers  from  stom- 
acace  by  the  following :  There  is  no  foetor  from  the  mouth. ;  the 
children  become  affected  before  dentition,  the  starting  point  of 
the  disease  is  not  the  mucous  membrane,  but  the  deeper  parts ;  the 
swelling  of  the  gum,  preceding-  the  falling  out  of  the  tooth,  seems 
to  be  limited  and  well-defined,  so  that  it  rather  resembles  parulis 
than  stomacace ;  the  gums  do  not  bleed.  From  noma  this  malady 
dififers  by  the  absence  of  the  gangrenous  odor  and  of  gangrene  of 
the  soft  parts. 

Among  the  foetid  ulcerative  stomatites  there  are  also  to  be 
included  inflammations  of  the  oral  cavity  depending  upon  gen- 
eral infectious  diseases,  as  diphtheria,  small-pox,  scarlet-fever ; 
but  in  a  diagnosis  all  these  forms  of  stomatitis  are  of  no  special 
value,  because  they  appear  after  all  other  symptoms  of  these  dis- 
eases have  developed  so  distinctly  that  the  diagnosis  cannot  be 
difficult. 


SEMEIOLOGY  OF  THE  APPETITE. 

Increased  appetite  is  of  favorable  meaning  if  it  appears  in 
the  child  during  convalescence  from  an  acute  febrile  disease  or 
any  other  emaciating  sickness.  Such  an  appetite  does  not  usually 
last  long,  disappearing  as  soon  as  the  child  entirely  recovers. 
Gluttony,  as  a  physiological  occurrence,  is  observed  in  nurslings 
in  the  first  months  of  life,  being  the  most  frequent  cause  of  dys- 
pepsia and  other  intestinal  disorders,  because  at  this  age  the 
child  does  not  refuse  to  swallow  more  milk  than  it  can  digest, 
(lluttony  is  also  favorable  to  the  development  of  obesity  in  nurs- 
lings. As  a  pathological  occurrence  an  increased  appetite  is  ob- 
served in  some  rachitic  children,  as  well  as  in  idiots,  diabetic  pa- 
tients and  in  chronic  diarrhcea. 

Loss  of  appetite,  bordering  sometimes  upon  aversion  to  food^ 
is  observed  in  all  febrile  diseases,  in  stomach  and  mouth  dis- 
eases and  in  hysteria. 

Loss  of  appetite,  as  a  single  and  most  important  symptom  of 
which  the  parents  complain,  is  often  observed  in  children  seven 
to  twelve  years  of  age,  manifesting  at  the  same  time  a  typical 
picture  of  malnutrition,  which  could  be  named  school  ancumia. 
Such  children,  being  comparatively  tall,  have  a  narrow  chest,  are 
considerably  emaciated  (so  that  all  ribs  may  be  counted  by  the 
eye),  manifest  paleness  of  the  skin  and  mucous  membranes  (but 
this  pallor  is  not  so  developed  as  in  chlorosis),  and  suffer  from 
complete  loss  of  appetite,  especially  with  regard  to  meat.  They 
usually  are  constipated  and  often  complain  of  headache.  During- 
summer  these  patients  improve  and  eat  better,  but  with  the  com- 
mencement of  school-lessons  the  appetite  again  declines,  and  so 
the  trouble  continues  up  to  twelve  or  fourteen  years,  when  the 
patient  seems  as  if  regenerated,  begins  to  eat  more  and  grows 
stouter. 

The  same  picture  is  to  be  seen  in  some  cases  of  chronic 


SEMEIOLOGY   OF  THE  APPETITE 


113 


stoinach  catarrh  or  chronic  dyspepsia,  so  that  oftentimes  it  is 
difficult  to  say  whether  the  loss  of  appetite  depends  upon  the 
anaemia,  or  both  diseases  depend  upon  the  stomach  catarrh.  The 
latter  proposition  becomes  more  reasonable  if  the  tongue  is  thickly 
coated,  the  patient  often  complaining  of  eructations  or  even  nau- 
sea, if  he  sometimes  has  pains  in  the  abdomen,  while  constipation 
follows  diarrhoea,  and  if  there  may  always  be  noted  a  yellowish 
tint  of  the  conjunctivae. 

Despite  this,  however,  the  question  often  remains  undecided 
whether  such  children  suffer  from  symptoms  of  stomach  catarrh, 
because  their  aucemia  produces  diminished  secretion  of  gastric 
juice,  and  thus  makes  them  especially  predisposed  to  stomach  dis- 
eases (Dyspepsia  nervosa). 

The  differentiation  of  stomach  catarrh  from  nervous  dys- 
pepsia may  be  materially  assisted  by  examining  the  stomach  with 
the  tube.  The  period  of  duration  of  food  in  the  stomach  in  nerv- 
ous dyspepsia  remains  normal  (about  six  or  eight  hours  after  a 
light  dinner  the  stomach  is  empty ;  in  stomach  catarrh  this  period 
is  longer).  It  is  noteworthy  that  in  nervous  dyspepsia  the  pa- 
tient's physical  condition  has  great  influence  upon  his  appetite. 

The  so-called  anorexia  hysterica  is  most  often  found  in  young 
girls,  in  age  from  ten  up  to  seventeen  years,  frequently  being 
the  first  symptom  of  hysteria.  The  trouble  is  usually  first  mani- 
fested under  the  influence  of  an  idea  (the  desire  to  become  thin, 
to  excite  sympathy  or  to  exact  a  great  deal  of  attention,  or  be- 
cause of  spasms  of  the  oesophagus,  vomiting,  etc.)  ;  the  patient 
begins  to  eat  much  less  than  formerly,  and  very  soon  entirely 
refuses  food  or  drink.  Absolute  starving  produces  the  most  intense 
emaciation  of  the  organism  (there  remain,  as  it  is  said,  only 
skin  and  bones),  marked  weakness  (the  patient  cannot  either 
stand  or  sit),  the  extremities  become  cold  and  cyanotic.  When 
the  patient  reaches  such  a  stage  of  emaciation,  then  a  fatal  ter- 
mination is  possible. 

In  hysterical  anorexia  it  is  somewhat  characteristic  that  the 
patient's  condition  usually  improves  quickly  if  taken  to  the  hos- 
pital and  there  fed  through  a  tube.  A  prolonged  feeding  through 
a  tube  is,  however,  seldom  necessary,  as  the  patient  usually  begins 
to  take  food  in  the  natural  manner  after  two  or  three  days. 

A  child  sometimes  refuses  food  not  because  of  a  bad  appe- 


114  SEMELOLOGV  OF  THE  APTETITE 

tite  but  on  account  of  entirely  different  reasons.  I  refer  here  to 
nurslings  disinclined  to  take  the  breast.  The  child  may  refuse  to 
take  the  breast  either  from  birth,  or  after  a  term  of  nursing 
may  then  cease  taking  the  natural  food. 

If  the  neiv-born  child  should  not  take  the  breast  during  the 
first  day  of  life,  such  an  event  does  not  prove  anything,  being 
of  very  frequent  occurrence  and  onl\-  temporary  :  but  if  he  con- 
tinues refusing  the  breast  on  the  second  or  tliird  da}'  then  one 
must  be  inquisitive. 

All  causes  upon  which  the  refusal  of  the  breast  may  depend 
may  be  divided  into  two  groups:  (i)  Either  the  child  cannot 
suck;  or  (2)  he  has  nothing  to  suck. 

The  child  cannot  nurse  the  breast  either  because  he  is  too 
weak  (abortive),  or  he  was  lx)rn  in  a  condition  of  asphyxia  and 
suffers  from  atelectasis,  or  there  is  a  maldevelopment,  as  hare-lip. 
cleft-palate,  or  mikrostomia. 

In  the  other  class  the  child  does  not  take  the  breast  because 
it  is  entirely  empty,  or,  even  when  it  contains  milk,  he  can  get 
nothing  because  the  breast  is  too  firm  and  too  heavy  for  the 
child  ;  or  the  nipple  is  not  very  well  developed. 

If  the  child  took  the  breast  during  the  first  da\s  of  life,  but 
later  on  refused,  then  it  mostly  depends  ui)on  thrush  or  u])on 
the  presence  in  the  mouth  of  small  ulcers,  aphthous  or  sxphilitic, 
as  well  as  upon  fissures  of  the  lips,  which  cause  pain  ujxju  the 
act  of  suckling.  It  sometimes  occurs  that  the  baby  readily  takes 
the  bottle,  but  refuses  the  breast  (as  the  latter  requires  more 
force),  or  suckling  proves  impossible  because  of  trismus  (in 
new-lx)rn,  in  tetanus;  in  elder  children  in  the  last  period  of  men- 
ingitis), or  because  of  snuffles  (cannot  breath  during  suckling), 
or  the  child  stops  taking  the  breast  as  a  result  of  general  debility 
because  he  is  an  abortive  one,  or  because  of  some  disease. 

Finally,  in  the  third  class  of  cases  the  cause  of  refusing  the 
breast  is  the  giving  up  too  early  of  the  breast  for  the  bottle.  It  is 
very  easy  to  spoil  a  child  by  instilling  in  him  different  bad  habits, 
as  it  is  likewise  easy  to  accustom  him  to  order.  Having  been 
used  to  a  sweet  sucking-bottle  or  to  sugared  cow's  milk,  the 
child  will  persistently  refuse  the  breast  (especially  if  the  latter 
be  hard  and  demands  from  the  child  a  certain  force  in  suckling) 
tiid  ends  by  completely  turning  away  from  the  breast. 


SEMK[()[,0(;V  OF  THE  APPETITE  II5 

In  all  such  cases  the  child  manifestly  does  not  take  the 
breast,  that  is,  his  lips  remain  plainly  immovable  when  the  nipple 
is  introduced  into  his  mouth  ;  he  makes  only  feeble  attempts  to 
suck  and  soon  stops,  bursting-  into  a  loud  cry. 

Besides  these,  still  other  cases  are  met  with,  as  when  the 
•child  starts  suckling  ravenously,  but  very  soon  chokes  and  stops 
nursing.  In  this  case  inability  to  nurse  depends  upon  the  great 
•quantity  of  milk  in  the  nursing  woman,  and  upon  the  weak  chest 
■of  the  child,  so  that  he  has  no  time  to  swallow  the  necessary 
quantity  and  therefore  chokes. 

The  laity  think  the  most  common  reason  why  the  child  does 
not  take  the  breast  well  is  the  too  short  frenulum  of  the  tongue. 
This,  however,  never  produces  complete  interference  with  suck- 
ling, although  it  may  hinder  it.  It  is  not  difiticult  to  recognize  the 
presence  of  a  short  frenulum.  If  the  free  end  of  the  tongue  be 
lifted  by  a  pallet-knife  it  will  be  seen  that  the  frenulum  is  stretched 
like  a  thin  membrane,  attached  too  far  in  front,  so  that  when 
the  tongue  is  pushed  out  or  lifted  a  groove  is  formed  on  its  top, 
which  is  absent  if  the  frenulum  is  not  short  (i.  e.,  attached  not 
"very  far  in  front). 

If  the  child  refuses  the  breast  because  there  is  no  milk,  or 
because  it  is  too  firm,  the  condition  can  be  learned  by  examining 
the  breast,  that  is,  by  squeezing  out  (milking)  milk. 

Mothers  often  complain  that  the  child  does  not  take  the 
"breast,  yet  an  examination  shows  that  the  child  sucks,  but  not  so 
long  as  the  mother  would  like.  Then  the  physician  has  to  decide 
the  question,  whether  the  child  soon  stops  suckling  because  of 
being  satisfied,  or  on  account  of  some  other  cause.  If  the  child 
becomes  satiated  quickly  he  may  still  appear  well  nourished  be- 
•cause  of  the  breast  being  very  rich  with  milk.  However,  if  he 
stops  suckling  because  of  general  debility,  etc.,  then  he  starves 
■continually  and  progressively  grows  thin. 

This  question  may  also  be  decided  directly,  namely,  by  weigh- 
ing the  child  before  nursing  and  immediately  after.  The  addi- 
tional weight  shows  accurately  the  quantity  of  milk  taken.  To 
judge  whether  this  amount  is  sufficient  one  may  be  guided  by 
Snitkin's  data,  according  to  which  the  child  nurses  on  the  "irst 
■day  one  one-hundredth  of  his  weight  (30  grms.,  or  one  ounce), 
and  then  every  day  adding  one  gram  more,  so  that  by  the  end 


Il6  SEMEIOLOGY  OF  THE  ArPETITE 

of  the  first  month  he  takes  about  two  ounces ;  at  the  end  of  the 
third  month  about  four,  etc.,  until  the  sixth  month;  after  that 
time  the  quantity  of  sucked  milk  remains  approximately  the  same. 

In  private  practice,  because  of  lack  of  proper  scales,  one  must 
content  himself  by  the  approximate  determination  of  milk. 

Increased  thirst  occurs  in  children  oftener  than  gluttony.  It 
is,  for  instance,  observed  frequently  in  rachitic  children,  even 
when  they  do  not  suffer  from  diarrhoea,  nor  from  increased  sweat- 
ing. Polydipsia  is  further  a  constant  symptom  of  diarrhoea  and 
diabetes,  false  or  true.  In  many  cases  copious  drinking  of  milk 
or  sweet  tea,  especially  in  the  night-time,  depends  simply  upon 
a  bad  habit  and  upon  the  fact  that  such  children  are  fond  of  the 
taste  of  the  beverage.  If  the  milk,  for  instance,  be  changed  to 
plain  water,  it  will  he  immediately  noticed  that  the  child  does  not 
drink  so  much  because  of  thirst  as  of  habit. 

In  children  oftener  than  in  adults  a  perverted  appetite  is 
met  with,  the  so-called  pica,  which  manifests  itself  by  the  child 
being  passionately  desirous  for  some  uneatable  things,  as  chalk, 
lime,  sand,  etc.  This  symptom  I  have  noticed  most  often  in 
rachitic  children. 


DISEASES  OF  THE  THROAT. 

Acute  inflammations  of  the  mucous  membrane  of  the  fauces, 
the  so-called  sore  throats,  occur  in  childhood  very  often ;  but, 
since  children  younger  than  five  years  visually  do  not  complain 
of  painf\d  deglutition,  it  is  very  easy  to  overlook  a  sore  throat, 
provided  the  physician  does  not  strictly  observe  the  rule  to  ex- 
amine the  throat  in  every  diseased  child,  especially  in  febrile  con- 
ditions. The  rigid  fulfilment  of  this  rule  is  the  chief  means  of  a 
correct  diagnosis  of  throat  diseases  in  children.  In  many  cases, 
especially  in  nurslings,  inspection  alone  is  insufficient;  one  must 
also  feel  the  throat  with  the  finger,  by  which  it  is  very  easy  to 
discover  a  retro-pharyngeal  abscess. 

Sore  throat  is  always  manifested  by  a  reddening  and  swelling 
of  the  mucous  membrane  of  the  tonsils  and  soft  palate ;  some- 
times these  symptoius  are  all  that  appear,  while  again  whitish 
or  yellowish  islets,  or  patches,  and  a  diffuse  coating  appear  on  the 
red  surface. 

DISEASES  OF  THE  THROAT  CHARACTERIZED  BY  A 
REDDENING  OF  THE  MUCOCS  MEMBRANE  OF 
THE  TONSILS  AND  SOFT  PALATE. 

Here  must  be  included  first  of  all  simple  or  catarrhal  sore 
THROAT — angina  catarrhalis.  This  disease  appears  either  pri- 
marily as  a  result  of  exposure  to  cold,  in  entirely  healthy  chil- 
dren, or  secondarily  during  exacerbations  of  a  chronic  catarrh  of 
the  throat,  especially  in  scrofulous  children  with  hypertrophied 
tonsils,  or  in  acute  infectious  diseases,  namel\ ,  in  influenza, 
scarlet-fever  and  measles. 

Genuine  catarrhal  sore  throat,  angina  catarrhalis  rlicn- 
matica,  occurs  quite  seldom,  more  rarely  than  other  forms  of  sore 
throat  accompanied  by  spots.  This  disease  is  characterized  by  a 
considerable  fever  (in  older  children  by  painful  deglutition)  and 
redness,  with  swelling  of  the  mucous  membrane  of  the  tonsils  and 


Il8  DISEASES    OF    THE    THROAT 

soft  palate.  In  two  or  three  days  recovery  occurs.  If  similar 
attacks  take  place  repeatedly  in  a  child  during  autumn  and  winter, 
and  if  the  tonsils  are  enlarged,  or  there  are  some  other  signs  of 
chronic  catarrh  of  the  throat,  as  dilatation  of  the  vessels  and  swell- 
ing of  the  glands  of  the  posterior  walls  of  the  pharynx  whose 
mucous  membrane  is  usually  dry,  then  we  have  to  deal  with 
an  exacerbation  of  the  chronic  catarrh,  the  fever  being  in  such 
cases  insignificant  and  sometimes  even  entirely  absent. 

Catarrhal  sore  throat  as  an  accompanying  symptom  of  an  in- 
fectious disease,  differs  from  a  primary  sore  throat  by  the  char- 
acteristic signs  of  the  latter:  In  la  grippe  snuffles  is  always  pres- 
ent, and  often  also  cough  ;  in  scarlet-fever  a  characteristic  eruption 
on  the  skin  ap])ears  at  the  end  of  the  first  twenty  hours ;  in  mea- 
sles, however,  the  diagnosis  may  be  aided  by  the  mucous  mem- 
brane of  the  fauces  remaining  normal  on  the  first  day  of  the 
fever,  and  on  the  second  or  third  day  there  appears  not  a  diffuse 
redness,  but  a  spotted  one.  Spots  of  the  size  of  a  pea  appear 
in  limited  number  on  the  soft,  and  partly  on  the  hard,  palate,  on 
the  normal,  i.  e.,  not  reddened  mucous  membrane;  the  dift'usc 
hyper^emia  occurring  later  on,  for  instance,  after  twenty-four 
hours,  when  separate  spots  disa])pear.  They  are  easier  seen  on 
the  other  parts  of  the  mouth,  especially  on  the  mucous  membrane 
of  the  lips  and  cheeks.  (About  the  diagnostic  value  of  this  prod- 
romal rash  see  Diseases  of  the  Mouth,  page  96.) 

In  scarlet  fever,  from  the  very  first,  the  redness  of  the  fauces- 
is  also  not  of  a  dift'use  character,  but  consists  of  very  small  points. 
The  spots  are  much  smaller  than  the  patches  in  measles,  are 
situated  closely  together,  and  sometimes  one  may  notice  that  they 
are  produced  by  petechia.  If  the  scarlatinal  eruption  of  the  soft 
palate  is  not  accompanied  by  punctate  haemorrhages  it  very  soon 
becomes  converted  into  a  diffuse  redness  which  to  some  extent  is 
characteristic,  because  in  the  beginning  it  occupies  the  center 
of  the  soft  palate  and  is  limited  by  very  abrupt  edges  (map-like 
redness),  while  in  simple  catarrhal  sore  throats  the  tonsils  become 
affected  more  often,  and  the  redness  never  differs  decidedly  from 
the  normal  mucous  membrane.  After  one  or  two  days  the  specific 
character  of  the  scarlatinal  catarrhal  sore  throat  disappears,  the 
redness  becoming  diffuse  and  spreading  over  the  tonsils  and  pos- 
terior   wall  of  the  pharynx. 


DISEASES  OF  THE  TIJROAT 


119 


DISEASES  OF  THE  THROAT  MANIFESTED  BY  FOR- 
MATION ON  THE  TONSILS  OF  WHITISH-YPiLLOW 
ISLETS. 

FoLLicuLArt  Sore  Throat — aiii^iiia  foUicularis. — Inflamma- 
tion of  the  follicles  results  in  the  appearance  on  the  reddened  sur- 
face of  the  tonsils  of  a  considerable  number  of  yellowish,  round, 
slightly  elevated  islets  or  plugs  the  size  of  a  pin's  head.  This 
angina  differs  from  all  other  spotted  sore  throats  by  the  equable 
size  and  rei^tilar  shape  of  the  islets,  so  that  the  tonsils  look  like  a 
"starry  sky"  (Stromeyer).  The  eruption  of  the  islets  never  ex- 
tends beyond  the  margins  of  the  tonsils.  This  disease  starts  from 
the  very  first  with  high  fever,  sometimes  with  vomiting,  and  may 
therefore  create  a  suspicion  of  scarlet  fever,  inasmuch  as  scarla- 
tinal sore  throat  sometimes  develops  in  the  form  of  a  follicular 
one.  The  doubt  cannot  last  longer  than  twenty-four  hours,  i.  e., 
until  the  appearance  of  the  scarlatinal  rash. 

Lacunar  sore  throat — angina  lacnnaris — differs  from  the 
preceding  by  the  shape  and  color  of  the  islets.  On  the  reddened 
tonsil  there  are  noticeable  irregular,  sometimes  chinky,  figures  of 
an  entirely  zvhite  color.  Here  we  do  not  deal  with  elevations  of 
the  mucous  membrane,  i.  e.,  not  with  swollen  follicles,  but  simply 
with  an  accumulation  of  catarrhal  secretion  (mucus,  epithelium, 
fungi)  in  the  hollows,  which  are  so  abundant  in  the  tonsils,  espe- 
cially when  they  are  hypertrophied.  If  the  plugs  of  the  lacunas 
are  of  a  purely  white  color,  then  the  diagnosis  is  easy,  because  in 
other  punctate  sore  throats  the  islets  are  of  a  yellowish  or  grayish 
tint ;  if,  however,  the  lacunas  are  filled  out  with  muco-purulent  se- 
cretion and  look  like  islets,  then  the  disease  may  be  regarded  as  a 
spotted  diphtheria.  The  latter  has  two  peculiar  signs,  which 
should  aid  the  diagnosis  immediately,  or  at  least  not  later  than 
twenty-four  hours.  The  first  peculiarity  of  diphtheria  is  that  the 
exudation  (wherever  diphtheria  may  be — in  the  throat,  intestines, 
etc. — it  is  immaterial)  first  occupies  the  eminent  parts  of  the  mu- 
cous membrane  (in  dysentery,  for  instance,  the  tops  of  the  villi), 
and  therefore  the  diphtheritic  process  will  aftect  first  not  the  cavity 
of  a  tonsillar  hollow,  as  occurs  in  lacunar  sore  throat,  but  the 
edges  of  the  latter.  To  be  able  to  find  out  minutely  the  localiza- 
tion of  the  islets,  it  is  necessary,  of  course,  that  the  patient  should 
show-  his  throat,  but  this  is  often  not  possible  with  children.     In 


I20  DISEASES    OF    THE    THROAT 

such  a  case  one  must  postpone  the  final  decision  until  the  next 
day,  meanwhile  taking  advantage  of  the  other  peculiarity  of  diph- 
theria, namely,  its  liability  to  spread  over  the  surface.  If,  on  the 
next  day,  the  islets  have  become  larger  and  some  of  them  con- 
fluent, having  formed  patches,  then  it  is  probable  that  we  have  to 
do  not  with  a  lacunar,  but  with  a  diphtheritic  sore  throat. 

Lacunar  sore  throat  begins  and  continues  with  high  fever 
(nearly  40  degrees  C. — 104  degrees  F.)  and  has  a  cyclic  course, 
ending  with  crisis  on  the  third,  seldom  on  the  fourth,  day.  If 
however,  diphtheria  starts  with  high  fever,  it  always  has  a  pro- 
gressive course  during  the  first  days,  assumes  a  membranous  form 
and  never  terminates  so  quickly  without  the  serum  treatment. 
The  abortive  form  of  diphtheria  which  remains  until  the  end  as 
a  punctate  sore  throat  may  end  with  recovery  in  three  to  four 
da\s,  but  in  such  case  it  remains  as  a  purely  local  morbid  pro- 
cess, running  not  only  without  fever,  but  also  without  redness 
of  the  affected  mucous  membrane. 

Lacunar  sore  throat  is  to  be  considered  as  an  acute  infectious 
disease.  'J1iis  is  proven  by  its  cyclic  course  and  appearance  as 
family  epidemics  ;  the  latter  fact  makes  the  diagnosis  easier,  be- 
cause the  epidemics  of  diphtheria  cannot  occur  as  slight  sore 
throats  with  a  typical  course. 

Aphthous  sore  throat  is  characterized  by  the  formation  on 
the  mucous  membrane  of  the  soft  palate  and  tonsils  of  small  (the 
size  of  a  pea)  round,  superficial,  yellowish  ulcerations  with  decid- 
edly hypen-emic  edges.  It  is  not  easy  to  confound  this  morbid 
form  with  diphtheria  or  other  punctate  sore  throats,  because  the 
ulcers  are  never  confined  to  the  tonsils  alone,  but  are  always  ac- 
companied by  aphtha?  in  other  parts  of  the  oral  iiiucoiis  membrane, 
especially  on  the  tongue,  lips  and  gums. 

Aphthous  angina,  like  aphthous  stomatitis,  is  often  accom- 
panied with  considerable  fever. 

Punctate  diphtheria  differs  from  other  punctate  sore 
throats,  as  already  pointed  out,  by  two  peculiarities :  the  liability 
to  extend  over  the  surface,  and  primary  appearance  on  the  em- 
inences of  the  mucous  membrane.  Diphtheria,  even  when  mem- 
branous, often  runs  with  almost  normal  temperature,  but  its  punc- 
tate variety  may  be  almost  excluded  if  there  is  considerable  fever; 
if  we  have  to  deal  with  family  epidemics,  then  the  diagnosis  may 


DISEASES    OF    THE    THROAT  121 

1)6  easy,  owing  to  the  fact  that  typical  forms  of  diphtheria  occur 
simultaneously  with  abortive  spotted  forms. 

The  appearance  of  paralysis  in  the  patient  after  two  or  three 
•weeks  indicates  that  there  was  diphtheria,  notwithstanding  the  fact 
that  Gubler  long  ago  described  several  cases  of  paralvsi*^  very 
•characteristic  of  diphtheria  yet  developing  after  sim])le  sore 
throats ;  but  his  observations  were  made  in  pre-bacteriological 
times.  More  demonstrative  are  the  cases  of  Bourges,  of  a  diph- 
theritic paralysis  after  streptococcus  angina,  and  those  of  Fiit- 
terer ;  at  any  rate,  the  occurrence  of  paralysis  after  non-diphther- 
itic sore  throat  is  so  infrequent  that  it  may  be  disregarded. 

DISEASES  OF  THE  THROAT  ACCOMPANIED  BY  THE 
FORMATION  OF  COATS  OR  MEMBRANES. 

In  a  normal,  non-h}pertrophied  tonsil  there  may  always  be 
-seen  in  its  center  quite  a  large  hollow  (lacuna)  of  an  ovai  shape 
with  its  longest  diameter  from  above  downward.  This  hollow  is 
sometimes  tilled,  in  a  catarrhal  or  parenchymatous  sore  throat, 
with  a  mucous  plug  ( as  in  lacunar  angina  the  small  hollows  are 
iilled),  and  then  a  white  spot  of  the  size,  for  instance,  of  the  end 
'Of  a  small  pencil,  appears  in  the  center  of  the  swollen  and  red- 
-dened  tonsil.  The  spot  is  so  firmly  adherent  that  it  cannot  be  re- 
moved with  a  brush  and  simulates  therefore,  as  well  as  by  its 
■size,  a  diphtheritic  sore  throat. 

This  variety  of  lacunar  sore  throat  is  often  accompanied  by  a 
considerable  swelling  of  the  whole  gland — angina  parench}'ma- 
rtosa — and  often  terminates  in  the  formation  of  an  abscess. 

The  beginning  of  the  disease  is  manifested  by  violent  fever, 
usually  associated  with  chills,  and  in  older  children  by  difficult 
•deglutition. 

The  white  spot,  developing  on  the  site  of  a  lacuna,  has  some 
peculiarities  by  which  it  can  be  differentiated  from  a  diphtheritic 
coating : 

(i)      It  akvays  occupies  the  center  of  the  tonsil. 

(2)  It  always  has  an  ozhiI  form  with  the  longest  diameter 
from   above    downwards. 

(3)  Its  edges  are  sharply  limited,  the  surface,  however, 
a^eaching  the  mucous  membrane,  is  seldom  elevated. 

(4)  Its  color  is,  at  the  start,  intensely  zvhite. 


122  DISEASES    OF    THE    THROAT 

(5)  The  size  of  the  spot  remains  stationary  during  several' 
days.  On  the  other  hand,  the  diphtheritic  coating  is  of  grayish, 
or  yellowish  tint,  is  irregular  in  its  contour  and  grows  larger 
every  day,  extending  not  only  over  the  tonsils,  but  usually  also- 
to  the  soft  palate  (uvula)  and  posterior  wall  of  the  pharynx. 

Herpetic  sore  throat  or  herpes  of  the  throat — herpes  toii- 
sillarum,  sive  angina  herpetica — is  characterized  by  the  appear- 
ance on  the  tonsil  of  a  group  of  thickly-crowded  vesicles  which 
very  soon  rupture  and  leave  in  their  place  an  erosion,  surrounded 
by  a  bright-red  ground.  The  erosion  soon  becomes  covered  with 
a  fibrinous  membrane  which  simulates  diphtheria.  The  eruption 
of  the  small  vesicles  and  the  formation  of  the  yellowish  coating  is 
preceded  by  a  febrile  condition  of  two  or  three  days'  duration,, 
sometimes  very  severe. 

The  disease  terminates  in  recovery  in  three  or  four  days. 

If  the  physician  did  not  see  the  vesicular  period  he  may 
easily  fall  into  a  mistake  by  accepting  the  grayish-yellow  surface 
of  the  erosion  for  the  diphtheritic  coating,  which  it  resembles  in 
its  color  and  outlines.  According  to  Cadet  de  Gassicourt,  herpes 
of  the  pharynx  is  the  most  frequent  source  of  error  in  this  respect, 
not  always  avoidable  by  a  single  examination ;  but  one  can  hardly 
agree  that  angina  herpetica  appears  as  a  frequent  cause  of  doubt,, 
as  this  form  of  malady  occurs  very  seldom. 

The  differential  points  from  diphtheria  consist  first  of  all  in 
the  ^etiological  factors  (angina  herpetica  arises  from  an  unknown 
cause  or  from  an  undoubted  exposure  to  cold,  diphtheria  from  in- 
fection) ;  then  in  the  persistent  and  high  prodromal  fever,  in  the- 
origin  of  the  coating  from  a  group  of  vesicles  (if  the  exudation 
be  removed  from  the  surface  of  the  ulceration  by  means  of  cotton,, 
it  is  often  easy  to  see  the  scalloped  margins  of  the  erosion,  alluding 
to  its  vesicular  origin),  in  herpes  of  the  lips  often  accompany- 
ing the  pharyngeal  herpes,  and  in  the  rapid  recovery.  ,. 

Membranous  or  pseudo-diphtheritic  (diphtheroid)  sore 
throat — pseudo-diphtheritis,  s.  angina  diphtheroidea,  s.  an- 
gina FiBRiNOSA  SIMPLEX. — We  employ  this  name  in  a  purely  clin- 
ical sense  and  understand  by  it  every  kind  of  inflammation  of  the 
mucous  membrane  occurring  with  the  formation  of  white  or 
whitish-yellow  coats  similar  to  diphtheritic,  but  independent  of 
the  diphtheritic  poison,  i.  e.,  sore  throats  in  which  Loffler's  bac- 


DISKASES    OF    THE    TIIKOAT 


i-'3 


illiis  cannot  be  found  either  by  microscopical  examination  of  the 
membranes,  or  by  making  cultures  on  blood  serum.  That  diph- 
theritic coatings  may  be  produced  not  only  by  Loffler's  bacillus, 
but  also  by  other  microbes,  is  now  undoubted,  but  what  microbes 
possess  this  peculiarity  we  do  not  know  positively ;  it  is  certain 
only  that  different  microbes  as,  for  instance,  streptococci,  Brisou's 
small  coccus,  staphylococci,  Frankel's  pneumo-bacillus,  etc.,  can 
produce  such  membranes.  On  the  basis  of  personal  observations 
made  during  late  years  on  the  clinical  material  of  the  hospitals  for 
contagious  diseases  (Moscow)  we  have  come  to  the  conclusion 
that  the  staphylococcus  and  streptococcus  are  the  most  frequent 
elements  in  the  pseudo-membranous  sore  throats  and  that,  for  in- 
stance, almost  all  cases  of  scarlatinal  diphtheria  may  be  called 
streptococcous  from  the  bacteriological  point  of  view.  It  is  also 
undoubtedly  truethatstreptococcous  pseudo-diphtheritic  sore  throat 
is  sometimes  observed  without  scarlet  fever,  viz.,  as  a  genuine 
independent  disease.  In  such  cases,  to  be  sure,  one  cannot  deny 
the  possibility  of  scarlet  fever  without  eruption ;  but  such  a  prop- 
osition may  be  sometimes  denied  positively  by  the  fact  that  the 
patient  immediately  after  streptococcous  pseudo-diphtheritic  sore 
throat  becomes  infected  with  scarlet  fever.  I  observed  such  a  case 
in  the  infectious  departments  in  December,  1892.  Klebs*  observed 
a  whole  family  epidemic  of  false  diphtheria  which  was  caused  by 
a  large  micrococcus  of  the  group  of  monades,  so-  that  ^'the  con- 
tagiousness is  not  to  he  held  as  a  proof  that  a  given  sore  throat  is 
not  of  psendo-dipJitheritic  nature." 

Dr.  Boulloche**  describes,  besides  the  streptococcous  sore 
throat,  three  other  forms  of  pseudo-diphtheritic  angina  due  to 
staphylococcus,  pneumococcus  and  coccus.  In  his  opinion  all 
these  infections,  including  the  streptococcus  variety,  are  not  con- 
tagious, being  usually  of  a  short  and  favorable  course. 

[Cruchet  classifies  the  various  forms  of  pseudo-membranous 
angina  into  the  following  groups  (besides  the  forms  above  named 
by  Boulloche)  : 

( I )  Pseudo-diphtheritic  or  diphtheroid  angina  due  to  vari- 
ous microbes,  but  not  to  Klebs-Loffler  bacilli. 


=^K!ehs:  Rcal-Eiicyclopacdia  of  Prof.  Eulciiburg,  Article  "Diphthcrm" 
p.  164. 

**Dr.  BouMoche:  Lcs  angincs  a  fausscs  membranes.  Paris,  1894,  pp. 
142-153- 


124  DISEASES    OF    THE    THROAT 

(2)  Pseudo-diphtheritic  angina  (kie  to  pseudo-diphtheria 
bacilli  (bacillus  of  Hoffmann). 

(3)  Pseudo-diphtheritic  angina  due  to  pseudo-diphtheria 
bacilli  other  than  Hoffmann's  bacillus. 

(4)  Diphtheritic  angina  due  to  Klebs-Loffler  bacillus.* 
The   latter   form   would,  in   our  opinion,  l)e  more  properly 

classed  un<ler  true  diphtheria,  as  done  by  Filatov,  rather  than 
placed  with  the  pseudo-membranous  forms. — Earle.] 

Raukhfuss  found  in  the  majority  of  cases  of  diphtheritic 
sore  throats  Loffler's  bacillus  in  the  stage  of  involution  and  ac- 
cepts such  cases  as  abortive  forms  of  diphtheria,  i.  e.,  as  diph- 
theria which  developed  in  a  person  almost  immune  to  the  poisoji 
of  this  disease.  According  to  his  obsers-ations  such  patients  do 
not  contract  this  disease  when  placed  among  those  suffering  with 
diphtheria,  and  do  not  convey  their  disease  when  placed  among 
the  healthy.** 

Since  false  diphtheria  does  not  dift'er  very  much  in  its  patho- 
logico-anatomical  features  from  the  genuine,  and  the  aetiology, 
being  the  most  important  differential  point  between  these  sore 
throats,  often  remains  obscure,  then  it  is  comprehensible  that  the 
diagnosis  of  false  diphtheria  exhibits  great  difficulties  in  the  very 
first  stage  of  the  disease,  while  the  timely  decision  of  the  question 
regarding  the  nature  of  the  disease  is  very  important  for 
the  prognosis  as  well  as  for  the  treatment.  The  main  thing  is 
that  pseudo-diphtheritic  sore  throats  are  held  as  slight  diseases 
(our  observations  completeh'  confirm  in  this  regard  those  of  Roux 
and  Yersin,***  who  never  here  observed  a  fatal  termination)  and 
it  is  not  necessary  to  isolate  such  patients — a  point  of  great 
urgency  in  a  case  of  genuine  diphtheria. 

A  prompt  and  exact  diagnosis  may  be  made  only  by  means 
of  the  bacteriologic  examination  (see  below),  and  in  case  the  lat- 
ter is  not  applicable  then  one  must  content  himself  with  the  more 
or  less  probable  proposition  and  l>y  clearing  up  the  question 
through  its  further  course. 

Numerous  investigations  by  many  authors  show  that  diph- 


*Arch.  dc  Med.  d.  Enf.  vi.,  1903. 

**Report  on  the  twenty-five  years'  activity  of  the  Children's  Hospital  of 
the  Prince  of  Oldenburg,  S.  Petersburg,  1894,  p.  334  (Russian). 
***See  Vratcli.,  1890,  p.  708  (Russian). 


DISEASES    OF    THE    THROAT  1 25 

theroid  sore  throats  are  far  from  being  rare;  from  Polievktow's 
table*  one  can  see  that  out  of  1.169  cases,  examined  in  different 
chnics,  pseudo-diphtheritic  sore  throat  (i.  e.,  not  caused  by  Lofif- 
ler's  bacilhis)  occurred  151  times,  viz.,  in  15  per  cent.  In  our 
chnic  (Moscow)  out  of  100  cases  pseudo-diphtheria  was  found 
26  times;  Martin  met  them  still  more  often,  namely,  of  112  cases, 
43  times,  i.  e.,  in  38.4  per  cent.  It  is  self-evident  that  the  per 
centage  of  false  diphtheria  will  be  still  greater  if  all  cases  of  sore 
throat  with  white  spots,  which  clinically  do  not  look  like  diph- 
theria altogether,  be  referred  to  this  disease. 

In  many  cases  pseudo-diphtheria  resembles  the  genuine  Loff- 
ler  infection  to  such  a  degree  that  even  the  most  experienced 
physician  is  unable  to  reach  a  final  conclusion  without  a  bacterioscop- 
ical  examination.  The  practical  rule  in  such  cases  is  therefore 
the  following:  If  the  physician  be  in  such  an  environment  that 
he  cannot  resort  to  a  bacteriological  examination,  he  should,  in 
all  doubtful  cases,  make  a  subcutaneous  injection  of  antitoxin  and 
isolate  the  patient. 

On  the  ground  of  clinical  and  cXtiological  data  one  may  with 
greater  or  less  reliability  exclude  pseudo-diphtheritic  sore  throat 
and  accept  diphtheria,  if  in  a  given  family  there  has  previously 
occurred  cases  of  this  malady,  if  the  latter  runs  without,  or  with 
insignificant,  fever  (but  not  vice  versa,  because  high  fever  does 
not  exclude  diphtheria)  ;  if  the  membranes  spread  over  the  edges 
of  the  tonsils,  for  instance,  on  the  soft  palate,  uvula,  nose  or 
larynx.  Among  the  pseudo-diphtheritic  sore  throats  only  the  scar- 
latinal variety  is  very  liable  to  extend  far  over  the  borders  of  the 
tonsils ;  all  other  forms  do  not  affect  the  soft  palate,  or  the  pos- 
terior pharyngeal  wall,  with,  of  course,  rare  exceptions. 

Albuminuria  is  not  infrequently  met  with  in  pseudo-diph- 
theria; but  the  subsequent  paralyses  in  diphtheria  only  (Bourge's 
case,  see  above). 

Pseudo-diphtheria  may  be  suspicious,  then,  when  in  a  given 
family  there  has  occurred  several  cases  of  a  seemingly  slight 
diphtheria ;  if  the  membranes  be  of  white  color  and  not  firmly  at- 
tached to  the  mucous  membrane ;  if  the  disease  began  as  a  severe 
catarrhal  sore  throat,  i.  e.,  with  a  high  fever  associated  with  in- 


*Traitsactions   of  the  Society   of  Pediatrics   in   Moscow   for   the   year 
1893-94,  P-   113- 


126  DISEASES    OF    THE    THROAT 

tense  redness  of  the  fauces  and  very  painful  deglutition.  It  is 
important  to  point  out  that  in  pseudo-diphtheria  the  membranous 
exudation  almost  never  extends  to  the  borders  of  the  tonsils,  so 
that  the  presence  of  a  coating  on  the  soft  palate,  uvula  and  the 
posterior  pillars  points  toward  a  genuine  diphtheria  ( it  must  again 
be  borne  in  mind  that  the  scarlatinal  false  diphtheria  is  an  excep- 
tion). Finally,  the  estal)lishment  of  the  diagnosis  may  be  con- 
firmed by  the  result  of  the  serum  treatment.  In  a  recent  case  (two 
or  three  days  from  the  beginning  of  the  disease)  of  genuine  diph- 
theria, a  decided  improvement  is  usually  obtained  in  from  twelve 
to  twenty-four  hours  after  the  injection  ;  in  the  case,  however,  of 
false  diphtheria  the  serum  does  not  influence  the  further  course 
of  the  morbid  process. 

Diphtheria  of  the  iwuces. — On  the  basis  of  pathologico- 
anatomical  data  only  such  a  sore  throat  should  be  regarded  as 
diphtheria  in  which  a  real  diphtheritic  exudation  is  developed ; 
when  so-called  coagulation  necrosis  of  the  mucous  membrane  is 
formed ;  in  the  period  of  recovery  the  necrotic  parts  should  slough 
ofif  by  reactive  suppuration  and  on  the  site  of  the  diphtheria  an 
ulcer  must  remain,  with  a  scar  after  healing  of  the  latter.  But  from 
the  clinical  standpoint  something  else  is  known  as  diphtheria, 
something  that  does  not  lead  to  necrosis  of  the  mucous  mem- 
brane, nor  to  the  formation  of  ulcers  or  scars,  although  such 
processes  here  may  have  place.  In  the  diagnosis  of  diphtheria  of 
the  throat  the  clinicians  are  guided  not  by  the  anatomical  changes 
of  the  mucous  membrane,  but  by  setiological  causes,  namely : 
diphtheria  of  the  throat  is  an  inflavDnation  of  its  mucous  inem- 
hrane  produced  by  the  poison  of  diphtheria — Loffler's  bacillus. 
It  is  immaterial  whether  the  throat  be  affected  by  a  croupous 
exudation,  or  the  inflammation  be  only  a  catarrhal  one ;  as  soon  as 
we  find  that  in  a  given  case  the  cause  of  sore  throat  is  Lofifler's 
bacillus  we  should  regard  such  morbid  process  diphtheritic  and 
should  so  characterize  it.  Thus  we  distinguish  the  catarrhal 
form  of  diphtheria,  croupous  diphtheria  and  gangrenous  or  septic 
diphtheria.  These  forms  are  all  varieties  of  the  same  pathological 
process — diphtheria  which  belongs  to  contagious  and  epidemic 
diseases. 

Since  not  only  Loffler's  bacillus  is  liable  to  produce  croupous 
or   diphtheritic    inflammation   of   the   mucous    membranes — i.    e.. 


DISEASES    OF    THE    THROAT 


127 


membranous  exudations,  but  other  microbes  may  also  have  similar 
action,  it  is  obvious  that  the  presence  of  a  membranous  coating 
alone  on  some  part  of  the  mucous  membrane  does  not  prove  that 
Ave  have  to  deal  in  any  given  case  with  diphtheria :  for  instance, 
in  a  severe  bloody  diarrhoea  there  occurs  diphtheria  of  the  large 
intestines  ;  but  this  does  not  mean  that  the  i)atient  contracted  the 
•diphtheritic  virus,  because  such  a  disease  is  usuall\-  produced  bv 
the  virus  of  another  affection — namely,  dysentery.  In  the  latter 
case  dift"erent  degrees  of  inflammation  are  met  also,  as  in  di])h- 
theria  of  the  throat,  and  therefore  catarrhal,  croupous  and  diph- 
theritic varieties  are  described — in  fact  the  analogy  is  complete. 
The  same  occurs  in  the  throat  during  scarlet  fever,  which  virus 
-always  produces  inflammation  of  the  mucous  membrane  of  the 
fauces ;  but  the  degree  of  this  inflammation  varies  in  diverse 
cases  from  a  simple  catarrhal  sore  throat  to  a  real  diphtheritic 
necrosis. 

Thus,  according  to  the  stage  of  development  of  local  and 
-general  symptoms  we  have  the  spotted  form  of  diphtheria,  mem- 
"branous  diphtheria,  and  the  septic  variety. 

The  spotted  or  catarrhal  form  of  diphtheria  is  characterized 
by  the  appearance  on  the  mucous  membrane  of  the  tonsils  of  yel- 
lowish and  grayish  islets  of  the  size  of  a  pin's  head  or  larger; 
fever  is  low  or  is  absent ;  the  submaxillary  glands  do  not  become 
swollen ;  the  whole  disease  may  end  with  recovery  in  three  or  four 
■days. 

Pathologico-anatomically  the  spotted  form  can  be  called 
neither  diphtheria  nor  croup,  because  there  is  no  fibrinous  exuda- 
tion, and  we  have  to  do  here  merely  with  a  slight  catarrh  of  the 
mucous  membrane,  where  yellowish-gray  spots  are  formed  by 
the  islet-like  deposit  of  a  mucous  exudation  in  the  upper  layers  of 
the  epithelium  (Heubner). 

If  this  form  does  not  go  farther,  but  stops  in  the  period  of 
the  formation  of  spots,  then  it  is  easy,  of  course,  for  it  to  be  mis- 
taken for  a  lacunar  or  some  other  catarrhal  sore  throat.  The  dif- 
ferences have  been  pointed  out  above.  Since  all  catarrhal  sore 
throats  usually  begin  with  considerable  fever,  diphtheria  alone 
being  an  exception,  then  a  normal,  or  nearly  normal,  temperature 
-in  spotted  angina  is  suspicious  of  its  diphtheritic  character ;  and 
if  at  the  same  time  there  are,  or  have  been,  cases  of  distinctly  de- 


128 


DISEASES    OF    THE    THROAT 


veloped  diphtheria  in  members  of  the  same  family,  then  the  diag- 
nosis is  more  than  probable. 

Such  forms,  indeed,  occur  very  seldom.  The  diagnosis  may 
be  aided  by  the  fact  that  every  day  the  separate  islets  grow- 
larger,  spreading  over  the  surface,  coalescing  and  forming  coats 
and  membranes  at  first  only  on  the  tonsils,  and  later  on  the  soft 
palate.  We  can  then  say  positively,  if  the  margins  of  the  uvula 
or  of  the  soft  palate  are  involved,  that  it  is  not  a  simple  catarrhal 
sore  throat,  but  diphtheria  or  scarlet  fever,  which  will  be  decided 
by  the  inspection  of  the  skin. 

Croupous  or  membranous  form  of  diphtheria  develops  either 
from  a  spotted  one,  or  appears  primarily  as  such,  starting  in  such 
case  like  catarrhal  sore  throat,  with  considerable  fever.  Inspection 
of  the  pharynx  o\\  the  first  day  of  the  disease  only  shows  signs  of 
a  severe  catarrhal  inllammation  :  bright-red  tonsils  and  soft  pal- 
ate and  oedematous  swelling  of  these  parts  with  enlargement  of 
the  uvula.  ( )n  the  second  day  the  exudation  appears  on  the  ton- 
sils, and  on  the  third  or  fourth  day  a  coating  is  also  seen  on  the 
soft  palate,  the  fever  at  the  same  time  persisting.  In  the  initial 
stage  the  membranes  are  firmly  attached  and  cannot  be  separated 
without  bleeding,  but  after  several  days  they  slough  ofif. 

Such  sore  throats  are  always  accompanied  by  swelling  of  the 
submaxillary  glands  and  those  of  the  neck,  which,  however, 
never  suppurate  (dififering  from  scarlatinal  sore  throat). 

Absence  of  fever  and  swelling  of  the  glands  does  not  exclude 
diphtheria. 

The  duration  of  the  croupous  variety  is  from  five  or  six  days 
to  two  or  three  weeks,  seldom  longer. 

Slight  as  diphtheria  may  appear  in  a  given  patient,  one  may 
never  be  sure  of  a  favorable  termination,  owing  to  the  liability  of 
an  extension  of  the  morbid  process  into  the  larynx  (croup). 
Apyretic  conditions  do  not  secure  one  from  such  an  event,  but 
seem  to  favor  it.  The  more  time  that  has  elapsed  since  the  begin- 
ning of  the  disease,  the  less  likelihood  of  the  larynx  becoming 
involved,  thus  making  the  prognosis  more  favorable.  Diphtheria 
is  very  liable  to  extend  over  the  surface  during  the  first  five  days, 
so  that  if  the  first  week  has  passed  happily  one  may  hope  that  na 
croup  will  develop. 

The  younger  the  child  the  less  is  the  distance  from  the  tonsils 


DISEASES    OF    THE    THROAT 


129 


to  the  larynx,  and  the  quicker  one  must  expect  the  occurrence  of 
false  croup  ;  in  children  younger  than  two  years  diphtheria  is  espe- 
cially dangerous,  because  its  extension  into  the  larynx  at  this  age 
is  almost  the  rule. 

Diphtheria  of  itself  may  be  dangerous,  as  well  as  by  its  action 
on  the  general  condition  of  the  organism  and  on  the  heart  activ- 
ity. The  thicker  the  false  membranes,  the  more  surface  they  cover 
and  the  stronger  the  odor,  the  severer  the  diphtheria.  The  spread- 
ing of  the  diphtheritic  process  to  the  posterior  pharyngeal  wall, 
and  especially  on  the  nasal  nmcous  membrane,  is  justly  regarded 
as  an  unfavorable  omen ;  of  the  same  value  is  the  extensive  swell- 
ing of  the  glands  of  the  neck  and  oedema  of  the  surrounding  sub- 
cutaneous tissue.  The  most  favorable  data  for  the  prognosis  are 
derived  from  the  temperature ;  according  to  Botkin,  high  fever  in 
diphtheria  permits  of  a  better  prognosis  than  a  low  temperature. 
Septic,  malignant  or  toxic  forms  of  diphtheria  differ  from 
the  preceding  by  the  character  of  the  local  appearances,  as  well 
as  by  the  general  condition  of  the  organism.  The  considerably 
enlarged  tonsils  are  coated  with  dirty-gray  exudation,  having  a 
very  foetid  odor ;  from  the  nose  there  is  a  sero-purulent,  some- . 
times  bloody,  liquid  discharge ;  the  neck  becomes  swollen,  not  so 
much  because  of  infiltration  as  from  oedema  of  the  cellular  tissues ; 
then  comes  collapse,  the  extremities  grow  cold,  the  pulse  feeble. 
These  cases  are  almost  always  fatal ;  if  symptoms  of  ady- 
namia appear  from  the  very  beginning,  then  the  patient  seldom 
survives  the  first  week ;  some  die  during  the  first  two  or  three 
days. 

Diphtheria  in  its  membranous  or  septic  variety  is  very  similar 
to  a  severe  scarlatinal  sore  throat,  which  is  also  characterized 
by  the  formation  of  diphtheritic  coats  in  the  fauces.  There  is, 
however,  not  only  a  clinical,  but  also  an  etiological  difference. 
The  difference  between  diphtheria  and  malignant  scarlatinal  sore 
throat  may  be  summed  up  in  the  following  manner :  Scarlatinal 
diphtheria  is  the  result  of  poisoning  of  the  organism  by  the  scar- 
latinal virus  (according  to  some  authors  by  the  secondary  infec- 
tion due  to  streptococcus),  and  therefore,  together  with  the  sore 
throat,  there  also  appears  a  scarlatinal  eruption  :  genuine  diph- 
theria, however,  arises  from  infection  by  the  diphtheritic  virus 
which  has  nothing  to  do  with  the  skin  and  thus  does  not  produce 


I30 


DISEASES    OF    THE    THROAT 


any  rash.  Therefore,  if  the  membranes  in  the  throat  be  devel- 
oped simultaneously  with  a  certain  rash  on  the  skin,  we  have  to 
do  with  a  scarlatinal  sore  throat,  or  scarlatinal  diphtheria ;  if, 
however,  there  is  no  rash — then,  with  a  common  diphtheritic  sore 
throat,  or  a  diphtheria.  But  this  rule,  being  true  of  the  over- 
whelming majority  of  cases,  admits  also  of  some  exceptions, 
namely  in  two  directions :  First,  there  occur  cases  of  scarlatinal 
diphtheria  without  eruption  (this  happens  usually  in  grown  per- 
sons), and,  secondly,  the  patient  may  contract  both  viruses,  those 
of  scarlet  fever  and  of  diphtheria,  and  then  it  may  occur  that 
in  a  scarlatinal  patient  there  will  develop  simultaneously  a  genuine 
bacillar  diphtheritic  sore  throat.  In  case  diphtheria  complicates 
scarlet  fever,  an  exact  diagnosis  from  the  inspection  alone  of  the 
sore  throat  is  impossible.  In  such  an  instance,  a  bacterioscopic 
examination  is  needed. 

Scarlatinal  diphtheria  appears  in  the  patient  during  the  early 
■days  of  the  disease,  usually  on  the  third  to  the  fifth  day ;  therefore, 
if  the  diphtheritic  sore  throat  shows  earlier  than  the  rash  or, 
vice  versa,  after  the  end  of  the  first  week,  then  we  may  think 
that  we  have  to  deal  with  a  genuine  diphtheria,  which  becomes 
the  more  probable  the  later  it  occurs.  Scarlatinal  sore  throat 
often  spreads  into  the  nasal  cavities,  but  almost  never  afifects  the 
larynx ;  therefore,  if  in  the  scarlatinal  patient  diphtheria  appears 
late  and  extends  into  the  larynx,  a  genuine  diphtheria  becomes 
very  probable ;  the  diagnosis  is  undoubted  if  the  characteristic 
diphtheritic  paralyses  occur  in  the  period  of  recovery. 

Cases  of  scarlet  fever  complicated  with  genuine  diphtheria  occur 
in  private  practice  very  seldom,  so  that  all  cases  of  diphtheritic 
angina  in  scarlet  fever  may  be  held  as  malignant  scarlatinal  sore 
throat  (or  as  scarlatinal  diphtheria).  This  being  the  case,  the 
physician  has  very  little  chance  of  making  a  mistake  in  diagnosis ; 
but  in  badly  constructed  hospitals,  where  all  contagious  patients 
are  placed  together  in  the  same  ward,  cases  of  double  infection 
are  common. 

In  doubtful  cases  of  all  kinds  of  spotted  or  membranous  sore 
throats  one  should  have  a  bacterioscopic  examination  of  particles 
of  membrane,  taken  from  the  patient's  throat,  because  at  the  pres- 
ent time  it  is  well  proven  that  in  all  cases  of  genuine  diphtheria 
the  Klebs-Loffler  bacillus  can  be  found  in  the  membranes.     He 


DISEASES    OF    THE    THROAT 


13^ 


who  is  familiar  with  the  question  of  the  diagnosis  of  diphtheria 
by  the  microscopic  examination  of  the  membranes  or  mucus,  will 
agree  with  Roux  and  Yersin,  that  "nothing  is  easier  and  quicker 
than  the  microscopic  examination  of  the  false  membranes,  and 
nothing  is  more  plain  than  obtaining  colonies  on  serum."  Thev 
advise  this  technique :  Particles  of  the  membrane  should  be  dried 
by  filter  paper  and  smeared  on  the  slide  so  that  the  latter  should 
be  covered  with  a  sheath  of  the  false  membrane,  but  not  of 
mucus  ;  then  the  slide  is  passed  through  a  flame  and  is  stained 
by  Loffler's  methylene  blue,  or  by  gentian-violet  according  to 
Gram.*  The  stained  specimen  is  washed  with  water  and  exam- 
ined wet  by  the  immersion  system.  The  diphtheritic  bacilli  are 
slightly  bent,  have  a  club-like  swelling  at  the  ends,  are  granular 
and  not  proportion  at  eh-  stained.  One  must  admit  that  the  swell- 
ing at  the  ends  and  the  unequal  staining  are  not  visible  in  all 
specimens.  In  membranes  of  a  true  diphtheria  such  bacilli  are 
met  with  constantly,  often  together  with  other  microbes.  For  the 
diagnosis  of  diphtheria  the  external  appearance  of  separate  bacilli 
is  not  so  much  of  value  as  their  method  of  grouping;  for  it  is 
characteristic  of  diphtheria  that  the  bacilli  are  situated  on  the 
specimen  not  in  groups,  but  as  if  forming  "felt."  The  microscop- 
ical examination  itself  takes  only  a  few  minutes  and  gives,  in  the 
majority  of  cases,  entirely  definite  results.  If  the  disease  is  near 
recovery  the  diphtheria  bacilli  diminish  in  number,  while  the 
secondar\-  microbes  increase — which  circumstance  is  of  importance 
in  the  prognosis.  In  slight  cases  the  diphtheritic  bacilli  are  very 
few  in  number  from  the  very  first,  but  there  are  a  great  many 
other  microbes. 

In  instances  where  the  number  of  bacilli  is  very  small  then, 
for  the  purpose  of  making  the  diagnosis,  Roux  and  Yersin  advise 


*Our  observations  in  the  clinical  infectious  departments  have  convinced 
us  that  Loffler's  bacillus  is  not  difficult  to  be  found  even  without  the  re- 
moval of  particles  of  membrane  by  the  forceps ;  it  is  sufficient  to  scrape 
the  surface  of  the  membrane  in  the  throat  by  a  platine-loop  and  to  put  the 
obtained  mucus  on  the  cover  glass,  to  dry  it  and  after  that  stain  with  Lof- 
fler's methylene  blue.  For  the  preparation  of  such  a  stain  we  take  a  sat- 
urated alcoholic  solution  of  methylene  blue,  filter  and  mix  it  together  with 
aqueous  solution  of  hydrate  of  potassium  (i:iooo),  while  for  every  lOO 
parts  of  the  latter  we  take  30  parts  of  solution  of  the  stain.  The  dried 
cover  glass  is  put,  together  with  the  mucus,  into  the  stain  for  ten  minutes, 
then  it  is  washed  off  with  water,  dried  with  filter  paper,  put  on  the  slide 
with  a  drop  of  copaiba  balsam,  and  the  specimen  is  ready. 


132 


DISEASES    OF    THE    THROAT 


the  employment  of  cultures  on  blood  serum,  to  which  is  added 
one-third  calf  bouillon  containing  one  per  cent,  sugar  and  pepton 
and  0.5  per  cent,  sodium  chloride.  This  serum  constitutes  such 
a  favorable  medium  for  diphtheria  bacilli  that  after  fifteen  hours 


A 


„  ',».-,/-■*'' 


\\\ 


f--^    »M 


^•/ 


<*       v:^ 


Fig.  IS — Diphtheria — A.  Culture  of  diphtheria  bacilH  on  serum  with  gela- 
tiiie.  B.  Several  diphtheritic  colonies.  C.  Diphtheria  bacilli.  (Dieula- 
foy.) 

entirely  distinct  colonies  are  obtained,  while  the  majority  of  the 
secondary  microbes  only  begin  at  that  time  to  grow.  It  is  suffi- 
cient to  scrape  with  a  platine  loop  the  surface  of  the  coagulated 
serum  in  two  or  three  tubes  which  are  then  placed  in  the  incubator 


DISEASES    OF    T[1E    TtlROAT 


133 


at  a  temperature  of  95  det^rees — 98  degrees  F.  (35  degrees — 37 
degrees  C).  Usually  after  ten  to  fifteen  hours  diphtheria  colonies 
are  distinctly  seen:  roundish,  grayish-white  elevated  spots  with 
the  center  less  transparent  than  the  periphery.  But,  as  similar 
colonies  may  be  produced  by  the  coccus,  one  must,  for  controlling, 
prepare  microscopic  specimens  and  stain  them.  Cultures  may 
also  be  obtained  from  the  dry  membranes.  It  is  then  necessary 
to  wet  them  in  sterile  water  (dry  diphtheria  bacilli  may  be  con- 
served very  long,  standing  a  temperature  of  96  degrees — 97  de- 
grees C. (179  degrees- 181  degrees  F.) during  one  hour.* (Fig.  15). 

Diphtheria  bacilli  seldom  occur  as  pure  in  plain  specimens  or 
in  cultures,  being  usually  mixed  with  some  other  microbes,  the 
importance  of  which  should  not  be  neglected,  because  from  them 
we  can  judge  of  the  malignancy  of  any  given  case.  Observations 
show  that  purely  bacillar  and  bacillo-coccus  sore  throats  run  a 
more  favorable  course  than  those  where  a  great  number  of  strep- 
tococci are  met  with,  together  with  the  specific  bacilli.  It  seems 
that  almost  all  cases  of  so-called  toxic  or  septic  diphtheria  could 
be  placed  among  these  bacillo-streptococcus  sore  throats. 

There  is  an  opinion  that  not  very  much  stress  should  be  laid 
upon  the  bacterioscopic  examination,  because  the  so-called  pseudo- 
diphtheria  bacilli  are  frequently  found  in  dilferent  kinds  of  sore 
throats,  as  well  as  in  the  mucus  of  the  mouth  of  entirely  healthy 
persons.  This  bacillus  is  analogous  to  a  genine  diphtheria  bacillus 
by  its  cultures  and  mode  of  development  on  blood  serum,  differing 
merely  by  not  being  poisonous  (i.  e.,  inoculation  of  guinea-pigs 
by  pure  cultures  of  this  bacillus  proves  negative).  On  this  ac- 
count Roux  and  Yersin  remark  that  in  non-diphtheritic  sore 
throats,  as  well  as  in  healthy  persons,  the  bacilli  are  always  very 
few ;  on  serum  there  are  obtained  one  to  four  colonies,  or  out  of 
several  tubes  only  in  one.  Therefore  they  affirm  that  the  diag- 
nosis of  diphtheria  by  means  of  cultures  cannot  be  obscured  by 
the  presence  of  pseudo-diphtheritic  bacillus,  because,  in  the  case 
of  diphtheria,  many  characteristic  colonies  may  be  obtained. 

[Graham  Smith,**  among  other  conclusions  on  this  distribu- 
tion of  diphtheria  bacillus,  state  as  follows : 


*Vratch,  1890,  p.  708. 

**Journal  of  Hygiene,  April,  1903,  p.  253;   (quoted  from  the  American 
Year  Book  of  Medicine  and  Surgery,  by  Gould,  1904,  p.  575)  • 


134  DISEASES    OF    THE    THROAT 

(i)  Diphtheria  hacilh  have  been  found  in  a  considerable 
proportion  of  persons  who  have  come  in  contact  with  cases  of 
diphtheria  or  with  other  infected  persons. 

(2)  Carefully  conducted  investigations  among  healthy  per- 
sons who  have  not  at  a  recent  date  been  in  contact  with  diphtheria 
cases  or  infected  "contacts/'  have  shown  that  znrulent  diphtheria 
bacilli  arc  very  seldom  (three  examples  among  1,316  persons) 
present  in  the  mouth  of  the  nornml  individual. — Earee.] 

Lately  Fraenkel  pointed  out  Neisser's  method  of  double  stain- 
ing to  be  the  right  way  of  determining  the  true  or  false  diph- 
theritic bacillus*  The  technique  of  this  method  is  not  difficult : 
the  dried,  smeared-on-the-cover-glass  particle  of  the  culture  to  be 
examined  is  put  for  from  one  to  three  seconds  in  an  acetic  acid 
solution  of  methylene  blue,  then  washed  with  a  watery  solution 
of  Bismarck  brown.  The  genuine  diphtheritic  bacilli  become  yel- 
lowish-gray, containing  at  the  ends  violet-blue  granules.  These 
granules  are  entirely  wanting  in  the  pseudo-diphtheria  bacilli. 
Frcenkel  asserts  that  any  micro-organism  cannot  be  held  as  a 
genuine  diptheritic  one  if  the  polar  bodies  be  not  manifested  by 
Neisser's  method  of  double  staining.  The  composition  of  the 
stains  for  Neisser's  method  is  the  following : 

(I)  Methylene  blue,  I.O  (gr.  xvi.)  ;  alcohol,  96  per  cent — 
20.0  (5  dr.)  :  glacial  acetic  acid,  50.0  ( i  oz.  5  dr.)  ;  Aq.  destill.  ad. 
looo.o  (lb.  iii).  (2)  Watery  solution  of  I'ismarck  brown 
2:1000. 

Scarlatinae  sore  thro.\t. — An  extensive  discussion  of  this 
variety  is  not  needed ;  it  is  sufficient  to  say  that  the  scarlatinal 
virus  possesses  the  property  of  producing  inflammation  of  the 
throat ;  the  character  of  the  afifection  depends  ui)on  the  malig- 
nancy of  the  virus  and  on  the  soil  on  which  it  develops  (indi- 
vidual immunit})  :  in  other  words,  the  intensity  of  the  scarlat- 
final  sore  throat  depends  upon  that  of  scarlet  fever  itself. 

In  mild  cases  (moderate  fever,  pale-pinkish  rash,  good  gen- 
eral condition)  we  find  a  simple  scarlatinal  sore  throat;  in  cases 
of  moderate  severity — the  follicular  or  lacunar  form  ;  in  grave 
cases — the  diphtheritic  form  in  all  its  possible  stages  of  evolution, 
but  without  Loffler's  bacillus. 

All  these  different  forms  of  sore  throat  we  regard  as  scar- 


*Bcr!incr  Kliiiischc  Jl'(n-hc)isclir.     1897,  No.  50. 


ni>i-:.\sr:.s  (>f    thi-:    riiRoAr 


135 


htinal,  provided  they  occur  simultaneously  with  the  scarlatinal 
rash  on  the  skin.  On  bacterioscopic  examination  we  constantly 
find  streptococci.  Of  course,  we  have  cases  where  Loffler's  bac- 
illus is  present,  but  such  cases  always  occur  in  a  combination  of 
scarlet  fever  with  diphtheria.  I  observed  such  a  case  in  a  family 
where  three  contagia  prevailed  at  the  same  time,  viz.,  scarlet 
fever,  diphtheria  and  varicella,  so  that  out  of  four  children  of 
this  family  one  had  diphtheria,  another  scarlet  fever  and  varicella, 
the  third,  scarlet  fever  with  diphtheria,  and  the  last  one  all  three 
diseases  together. 

Trousseau  distinguished  two  kinds  of  membranous  scar- 
latinal angina:  ( )ne  was  called  by  him  recent  sore  throat  (aii- 
i:;iiic  psciido-nioiibraiiciisc  precoce ) ,  the  other  late  ( tardive ) .  The 
former  occurs  in  the  period  of  eruption  ( the  second  up  to  the 
fourth  day )  always  being-  accompanied  1)\-  involvement  of  the 
nose  and  submaxillary  glands,  but  sparing  the  larynx  ;  it  cannot 
be  considered  as  diphtheria.  The  latter  variety  appears  in  the 
period  of  convalescence  (second  to  third  week)  and  extends  into 
the  larynx.  The  former,  according  to  Trousseau,  depends  upon 
an  infection  by  the  scarlatinal  virus,  the  latter,  by  that  of  diph- 
theria. Recent  bacterioscopic  investigations  amply  confirm  the 
correctness  of  his  views,  because  the  streptococcus  occurs  in 
fresh  scarlatinal  diphtheritic  sore  throats,  together  with  (^thcr 
microbes,  but  in  the  later  stages  there  is  Lotfler's  bacillus. 

I'lcerous  sore  thro.vt  (ani^ina  I'ineenti  or  I'ineent's  an- 
gina).— By  ulcerous  sore  throat  I  understand  ulcerous  destruc- 
tion of  the  mucous  membrane  of  the  tonsils,  based  on  the  same 
morbid  process  as  stomacace — an  ulcerous  fretid  inflammation  of 
the  mouth.  In  both  cases  the  mucous  membrane  becomes  swollen, 
takes  on  a  bluish  tint  and  easily  bleeds  on  touch.  The  affected 
mucous  membrane  very  soon  undergoes  superficial  necrosis  and 
decay,  with  the  subsequent  formation  of  an  ulcer,  covered  with 
a  thick,  soft,  dirty-yellow,  foul-smelling  deposit.  These  symp- 
toms, with  the  stench  from  the  mouth,  are  accompanied  by  a 
slight  fever  and  swelling  of  the  submaxillary  glands,  so  that 
this  form  of  sore  throat  highly  resembles  diphtheria. 

The  first  cases  of  ulcerous  sore  throat  I  observed  in  a  con- 
sultation with  Dr.  Schlossberg.  The  diagnosis  was  here  assisted 
by  the  fact  that  the  girl  had  a  pronounced  stomacace,  while  the 


136  DISEASES    OF    THE    THROAT 

simultaneously  pronounced  swelling,  the  bleeding  mucous  mem- 
brane of  the  mouth  and  the  friable,  soft  coating  contraindicated 
diphtheria. 

As  neither  myself,  nor  my  colleague,  had  heard  at  that  time 
of  such  a  form  of  sore  throat  our  diagnosis  was  made  only  as  a 
supposition  and  was  confirmed  by  the  successful  action  of  potas- 
sium chlorate.  Another  case  of  ulcerous  sore  throat  I  observed 
in  a  twelve-year-old  girl.  She  came  under  observation 
on  the  third  day  of  the  disease,  which  began  with  a  violent  fever 
and  painful  deglutition.  On  the  day  of  her  entrance  to  the  clinic 
the  following  symptoms  were  noted :  A  violent  stench  from  the 
mouth,  very  characteristic  of  stomacace,  although  the  gums  w^ere 
not  afifected ;  both  tonsils,  especially  the  left  one.  were  enlarged 
to  such  an  extent  that  the  uvula  was  compressed  by  them  and 
the  posterior  wall  of  the  pharynx  could  not  be  seen  ;  lx)th  tonsils 
and  partly  the  uvula,  were  coated  with  a  grayish-yellow,  very  fri- 
able and  thick  exudation  ;  under  the  angle  of  the  inferior  maxilla 
there  was  a  considerable  swelling  of  very  hard  consistence,  caused 
by  ])eria(lcnitis  ;  the  voice  had  a  nasal  twang;  fever,  39  degrees 
C.  (102  degrees  F.).  In  the  exudation  a  great  many  dilTerent 
cocci  were  seen,  bin  no  Lofller  bacilli  could  be  demonstrated. 

Although  the  gums  were  not  involved  in  this  case,  never- 
theless we  had  a  right  to  exclude  diphtheria  and  to  diagnosti- 
cate ulcerous  sore  throat  on  the  ground  of  the  characteristic 
stench,  the  appearance  of  the  exudation  and  solid  tumor  under 
the  angle  of  the  inferior  maxilla  (in  diphtheria  the  swelling 
of  the  subcutaneous  tissue  is  usually  of  the  oedematous  character). 
The  treatment,  which  consisted  especially  in  administering  in- 
ternally, and  applying  externally,  potassic  chlorate  (Bertolet's 
salt),  in  both  cases,  two  per  cent,  solution,  amply  confirmed  our 
diagnosis,  because  the  stench  had  diminished  by  the  following 
day.  and  at  the  same  time  the  local  appearances  in  the  throat  also 
decreased,  and  after  r.  week  the  patient  recovered  entirel}'. 

A  short  description  of  this  sore  throat  may  be  found  in  \'ol- 
ume  II  of  Traitc  cliniqiic  ct  pratique  des  maladies  des  enfants, 
by  Barthez  et  Sanne,  p.  226.  According  to  their  observations 
"angine  ulcero-membraneuse."  ulcero-membranous  sore  throat  (as 
they  call  this  form)  is  not  always  accompanied  by  stomacace;  in 
such  a  case  the  diagnosis  will  be  more  difficult  and  mav  be  assisted 


DISEASES    OF    THE    THROAT  I37 

l)y  the  aspect  of  the  affected  parts,  by  the  aetiology  (the  same  as 
for  stomacace)  and  by  the  prompt  action  of  potassium  chlorate. 
Very  distinctive  of  this  disease  is  the  characteristic  stench  from 
the  mouth,  as  in  stomacace,  being  entirely  different  from  that  in 
gangrene  or  diphtheria. 

Ulcerous  sore  throat  was  described  minutely  by  Professor 
Simanovsky  in  the  medical  journal  "Vvatch,""^  He  observed  this 
malady  occurring  as  a  small  epidemic  simultaneously  with  cases 
•of  ulcerous  aft'ection  of  the  oral  mucous  membrane  and  called  it 
pharyngitis  ulcerosa.  He  also  often  observed  aft'ection  of  the 
posterior  wall  of  the  pharynx  and  tonsils,  while  in  some  cases  the 
mucous  membrane  of  the  mouth  and  gums  remained  normal. 
The  ulcerous  lesion  of  the  throat  was  accompanied  only  by  verv 
slight  general  symptoms,  moderate  fever  or  no  elevation  of  the 
temperature.  The  disease  usually  lasted  from  seven  to  ten  days 
or  more.  Sometimes  only  one  tonsil  was  affected.  If  the  lesion 
of  the  gums  be  absent,  then  is  the  analogy  with  diphtheria  still 
greater,  because  albuminuria  is  of  frequent  occurrence  in  this 
sore  throat.  In  Simanovsky "s  cases  the  ulceration  of  the  gums 
was  always  present. 

Nevejin**  sums  up  the  symptomatology  of  ulcerous  sore 
throat  in  the  following  way  (  from  his  own  eight  cases  and  twenty- 
eight  cases  from  literature)  : 

(i)  Specific  odor,  being  the  same  as  in  stomacace,  but  dif- 
ferent from  that  in  diphtheria  and  scarlatinal  sore  throat. 

(2)  The  form  of  the  coating — it  looks  as  if  greasy,  grayish- 
yellow,    friable,   little   resembling   the   solid   diphtheritic    coat   or 

:any  fibrinous  exudation. 

(3)  Sympathetic  participation  of  the  mucous  membrane  of 
the  mouth  (even  in  the  form  of  a  very  slight  catarrh),  hence 
-visible  irritation  of  the  salivary  glands  and  persisting  salivation. 

(4)  The  presence  of  characteristic  ulcers. 

(5)  The  most  characteristic  solidity  and  enlargement  of 
the  submaxillary  glands,  without  simultaneous  oedema  of  the 
subcutaneous  tissue  (this  oedema,  due  to  periadenitis,  is  pathog- 
nomonic of  diphtheria  when  the  latter  is  associated  with  wide- 
spread coating  in  the  throat). 


*See  "Vratch,"  1890,  No.  1-7. 

^^Transactions  of  tlic  Society  of  Pediatrics  in  Moscow  (Russian),  1894, 


138  DISEASES    OF    THE    THROAT 

(6)  The  general  condition  of  the  patient:  good  pulse  and" 
preservation  of  physical  forces  simultaneously  with  apathy,  vast 
coats  in  the  throat  and  often  elevated  temperature. 

(7)  The  development  of  the  disease  is  favored  by  the 
same  conditions  of  exhaustion  of  the  organism  and  external  hygi- 
enic influences  as  in  stomacace  (Barthez  and  Sanne).  All  of  our 
patients  lived  in  a  bad  environment. 

(8)  The  prompt  action  of  chlorate  of  potassium,  which 
for  this  disease  is  of  the  same  value  as  quinine  in  malaria. 

(9)  Finally,  one  more  characteristic  difference  between 
diphtheria — absence  of  paralyses  in  the  period  of  convalescence. 

Bacteriosco])ic  examination  of  the  exudation  (staining  by 
Loffler's  nicthvlcne  blue)  in  the  ulcerous  form,  as  well  as  in 
stomacace,  alwavs  shows  fusiform  bacilli  with  sharp  ends  and 
spirilla;.  If  we  are  to  be  guided  in  the  diagnosis  of  ulcerous 
sore  throat  by  this  sign,  we  may  say  that  recent  and  slight  cases 
of  angin?e  ulcerosje  are  accompanied  neither  by  stench  from  the 
mouth,  nor  by  swelling  of  the  submaxillary  glands.  Without 
bacterioscopic  examination  such  slight  forms  cannot  be  diagnosed 
from  the  mild  lacunar  sore  throat. 

I  will  point  out,  by  the  wa>,  that  our  rule  is  to  begin  the 
treatment  of  an\-  "■fretid"  diphtheria  with  internal  doses  of  potas- 
sium chlorate. 

[These  fusiform  bacilli  and  spirilla;  were  first  described  by 
Mncent  in  the  years  1896- 1898  as  the  cause  of  ulcerative  angina. 
The  fusiform  bacillus  is  swollen  at  the  centre,  with  pointed  ex- 
tremities. It  is  generally  straight,  but  is  sometimes  curved  or 
bent  upon  itself  and  measures  6  to  12  micro.  It  is  encountered  in 
irregular  masses,  often  as  a  diplobacillus.  and  sometimes  two  are 
seen  lying  at  an  angle  to  each  other.  Their  motility  has  been 
questioned  by  a  few,  but  is  maintained  by  Xiclot  and  Marotte. 

The  bacilli  stain  readily  with  the  basic  stains,  but  are  gener- 
ally decolorized  by  Gram's  method. 

The  dimensions  of  the  spirillae  vary,  but  they  are  very  long 
and  of  equal  width  through.  They  are  observed  singly,  in  groups, 
and  are  sometimes  seen  in  an  inextricable  mass.  Their  motility 
may  be  retained  for  many  hours,  but  diminishes  rapidly  on  ex- 
posure to  air  or  cold.  Where  the  disease  process  is  superficial 
the  spirillum  may  be  absent,  but  in  the  deeper  lesions  the  combina^ 


DISEASKS    OF     fllK    THROAT 


139 


tion  is  invariable.  This  description  taken  from  Fischer's  article, 
"Report  of  Two  Cases  of  Ulcerative  Angina  and  Stomatitis,  As- 
sociated With  the  Fusiform  Bacillus  and  Spirillum  of  Vincent,"* 
is  confirmed  also  by  other  observers  (Sobel  and  Herman,**  Hess 
and  others).  Hess***  distinguishes  two  forms  of  Vincent's  ulcer- 
ous angina :  a  croupous  and  a  diphtheroid-ulcerous  form.     The 


Fig.   16 — The  bacilli   and  spiulla   of  VincL-nt    (after   Fisher). 

former  is  characterized  by  the  formation  of  pseudo-membranes 
without  any  loss  of  tissue,  the  latter  by  the  formation  of  more 
or  less  deep  ulcers.  Of  the  former  ouly  the  fusiform  bacillus 
is  characteristic,  while  in  the  latter  both  parasites  appear  simul- 
taneously. These  parasites  (fusiform  bacillus  and  spirochetes 
denticola)are  saprophytes  of  the  cavity  of  the  mouth  and  digestive 
apparatus.  The  bacillus  alone  may  cause  the  disease,  while  the 
spirilla  is  pathogenic  only  when  associated  with  the  fusiform 
bacillus.     (Fig.  16.) 

*Amcr.  Jour,  of  Med..  Sc.  September,  1003 
**Nczi'  York  Med.  Jour.,  January  7,  1901. 
^**Deut.  Med.  JJ'oeh..  190.3,  No.  42. 


140  DISEASES    OF    THE    THROAT 

Ulcerous  angina  may  be  easily  (listinjjuished  from  other  sim- 
ilar forms  by  the  following: 

(i)      Both  parasites  must  be  present  abundantly. 

(2)  Absence  of  diphtheritic  bacilli. 

(3)  Syphilis  may  be  excluded. 

(4)  In  the  superficial  layers  of  the  mucosa  staphylococci 
and  streptococci  are  occasionally  found. 

Sobel  and  Herrmann  had  under  their  observation  twelve 
cases  of  Vincent's  angina  and  in  all  of  them  the  above  described 
parasites  were  found  in  large  numbers. — E.\rle.] 

Syphh^itic  SORE  THROAT  occurs  in  two  forms,  condyloma- 
tous  and  ulcerous.  Angina  syphilitica  condylomatosa,  s.  condylo- 
mata faucii,  as  a  manifestation  of  hereditary  syphilis,  occurs  espe- 
cially in  small  children  from  two  to  five  years  of  age,  while  angina 
syphilitica  ulcerosa,  s.  nlccra  syphilitica  faucii  (syphilitic  ulcers  of 
the  fauces)  appears  usually  as  a  symptom  of  the  late  period  of 
syphilis  and  therefore  is  seen  mostly  in  older  children  after  seven 
years  of  age. 

The  favorable  situation  of  the  ci)nd\iomata  is  the  inner  sur- 
face of  the  cheek  ;  they  appear  first  of  all  on  the  corners  of  the 
mouth ;  then  on  the  soft  palate  and  more  seldom  the  tonsils  and 
the  tongue  become  affected. 

Condylomata  look  like  pinkish  white  patches,  considerably 
elevated  over  the  surrounding  mucous  membrane..  On  touch  they 
do  not  bleed  and  they  are  painless ;  reactive,  inflammatory  redness 
around  them  is  not  to  be  seen.  As  the  condylomata  are  caused 
by  the  proliferation  of  the  papillae  of  the  skin,  or  of  the  mucous 
membrane,  they  may  therefore  always  be  recognized  by  the  vil- 
lous structure,  appearing  as  very  small,  punctiform,  whitish  ele- 
vations, so  crowded  together  that  the  condvloma  looks  like  a  slen- 
der mosaic. 

The  development  of  condylomata  is  slow,  lasting  weeks,  but, 
being  painless,  they  are  often  overlooked.  It  is  seldom  that  con- 
dylomata of  the  mouth  and  fauces  constitute  the  sole  evidence  of 
syphilis;  usually  there  also  exist  sinuiltaneously  condylomata  on 
the  skin  and  very  often  circa  anuiii.  which  fact  aids  the  diagnosis 
very  much. 

As  the  condylomata  are  always  elevated  above  the  surface 
of  the  neighboring  mucous  membrane,  it  is  impossible  to  confound 


DISEASES    OF    THE    THROAT  I4I 

them  with  other  ulcers.  They  are  rather  more  hke  a  diphtheritic 
patch,  and  are  sometimes  recognized  as  such  if  occupying  only 
the  soft  palate  and  tonsils,  and  if  the  history,  together  with  the 
other  objective  symptoms  of  syphilis,  be  absent.  In  such  cases 
attention  must  be  given  to  the  color  of  the  patch  (condyloma  is 
of  pinkish-white  color,  the  diphtheritic  patch  of  yellowish-gray) 
and  to  its  structure. 

Angina  syphilitica  ulcerosa  is  characterized  by  the  appear- 
ance on  the  mucous  membrane  of  ulcers  of  different  size  and 
shape,  usually  with  sharply-cut  edges  and  a  dirty-yellow  floor. 
They  occupy  either  the  soft  palate,  often  producing  its  perfora- 
tion, or  the  tonsils  and  the  posterior  wall  of  the  pharynx.  Often 
there  may  be  seen  scars  of  old  ulcers  together  with  new  sores. 

The  course  of  the  disease  is  very  protracted  with  few  sub- 
jective symptoms.  .Sores  of  the  fauces  usually  occur  from  decayed 
gummata,  thus  corresponding  to  the  late  period  of  syphilis,  and 
therefore  there  is  very  often  observed,  as  accompanying  symp- 
toms, the  affection  of  the  bones ;  the  patients  usually  complain  of 
pains  in  the  legs  (increasing  in  the  night),  on  the  examination  of 
which  painful  periostites  on  the  anterior  surface  are  noted. 

Tubercular  and  lupous  ulcerative  processes  being  of  chronic 
course  could  be  confounded  with  syphilis  of  the  throat,  and  occur 
in  childhood  very  seldom.  Of  these  two  chronic  ulcerous  pro- 
cesses lupus  is  of  greater  importance  in  childhood.  The  picture 
of  destruction  in  lupus  is  very  similar  to  that  of  syphilis.  The 
diagnosis  is  based  on  : 

( 1 )  Accompanying  symptoms  (lupus  of  the  nose) . 

(2)  On  the  history  (no  signs  of  syphilis). 

(3)  On  the  result  of  treatment  with  iodine  (lupus  does  not 
yield  to  iodine,  while  syphilitic  ulcers  heal  quickly). 

[Gangrenous  Angina  (primary). — Besides  the  enumer- 
ated forms  of  angina  a  pritnary  gangrenous  angina  is  also  de- 
scribed. In  the  previous  editions  of  his  Semeiology  and  Diagnosis 
of  Children's  Diseases*  Prof.  Filatov  says:  "Barthez  and 
Sanne  also  describe  in  their  Text-Book  gangrenous  angina  which 
is  analogous  to  gangrene  of  the  cheek  (noma).  I  cannot  speak 
of  such  an  angina  from  my  own  experience,  as  I  never  saw  the 
same." 


*Prof.  Filatov's  Semeiology,  etc.    2nd  Russian  ed.  1891,  Moscow,  p.  84. 


142  DISEASES    OF    THE    THROAT 

E.  Oberwarth  collected  twenty-four  cases  of  primary  gan- 
grenous angina  (two  cases  have  been  reported  by  Fullerton  in 
The  Lancet,  June  7,  1902),  which  with  his  own  case'''*  make  a 
total  of  twenty-five  cases.  The  nature  of  this  morbid  process 
consists  in  a  necrosis  of  the  mucous  membrane  of  the  throat  ex- 
tending to  the  neighboring  soft  parts  of  the  mouth  and  larynx, 
and  thence  to  the  lips,  cheeks  and  occasionally  to  the  Eustachian 
tubes.  Anatomically  this  disease  is  shown  by  the  formation  of 
grayish-black  patches  with  sharp,  yellowish  edges  which  seem  to 
be  elevated  after  the  separating  of  the  crust.  Clinically  it  is 
characterized  by : 

(i)     A  foetid  odor  from  the  mouth,  fscal-like. 

(2)  Severe  pain  in  the  throat,  especially  during  the  act 
of  swallowing. 

(3)  Nasal  tone  of  the  voice. 

(4)  Occasional  presence  of  enlargement  of  the  cervical 
glands. 

(5)  Absence  of  fever  (the  temperature  is  even  subnormal). 

(6)  Cyanotic  tint  of  the  skin. 

(7)  General  collapse,  accompanied  by  psychical  depression. 

(8)  HcTemorrhages  from  the  capillaries,  small  veins  and 
large  vessels. 

(9)  Malignancy  of  the  course  (this  disease  being  always 
fatal).  ' 

The  course  of  the  affection  covers  three  or  four  weeks,  al- 
though cases  are  rei)orte(l  wherein  the  disease  continued  for 
eighteen  months. 

The  aetiology  is  unknown,  some  authors  contending  that  it 
is  always  of  secondary  origin.  Trousseau  thought  it  might  aft'ect, 
without  any  visible  cause,  entirely  healthy  persons,  quickly  lead- 
ing to  death.  According  to  Oberwarth  the  cause  of  the  disease 
is  some  microbe  resembling  the  diphtheria  bacillus.  In  his  case, 
a  twelve-year-old  boy,  Hansemann  conducted  the  post-mortem 
and  found  a  large  number  of  streptococci,  but  Oberwarth  does 
not  seem  to  be  willing  to  regard  them  as  the  cause  of  the  malady. 

This   disease   may  be   confounded    (i)    with    Vincent's   an- 


_**Primare  Angina  GangnTnosa  bei  einem  Knaben   (Dent.  Med.  Woch., 
1903,  No.  17  and  iS). 


DISEASES    OF    THE    THROAT  I43 

gina  (ulcerous  angina)  ;  (2)  zi'itli  diphtheria,  and  (3)  with 
syphilis. 

Angina  Vincenti  differs  from  the  gangrenous  form  ( i )  by 
its  benign  course;  (2)  by  the  odor  not  being  so  offensive,  i.  e., 
•does  not  resemble  the  gangrenous  odor  of  this  form,  and  (3) 
by  bacteriological  findings. 

The  bacteriological  examination  ;  the  peculiarity  of  the  odor  ; 
the  swelling  of  the  cervical  glands  (which  are  developed  in  diph- 
theria but  may  be  absent  in  gangrenous  angina)  may  easily  dif- 
ferentiate it  from  diphtheria. 

With  syphilis  it  may  be  confounded  according  to  Oberwarth. 
•especially  in  the  event  of  a  primary  affection  of  the  tonsils  with 
the  primary  chancre ;  in  the  latter  case  a  few  days  after  the  first 
complaints  there  appears  on  the  neck  an  enlargement  of  the 
glands  reaching  from  the  size  of  a  pigeon's  egg  up  to  that  of 
■one's  fist. 

Therapy  is  practically-  helpless  although  cauterization  with 
nitric  or  chromic  acid,  rinsing  of  the  mouth  and  throat  and  the 
administration  of  stimulants  arc  suggested. — Earle.] 


SEMEIOLOGY    OF    DIFFICULT    DEGLU- 
TITION—DYSPHAGIA. 

If  the  mother  complains  that  the  child  cannot  swallow  it 
does  not  necessarily  mean  that  there  exists  an  obstacle  to  the 
passage  of  food  from  the  mouth  into  the  stomach.  Sometimes,  as 
in  some  cases  of  diffuse  aphthous  stomatitis,  the  child  does  not 
even  attempt  to  swallow  the  food,  forcing  it  out  of  the  mouth. 
Numerous  small  ulcers  upon  the  tongue  and  other  parts  of  the 
mouth  may  render  chewing  so  painful  that  the  child  refuses  hard 
food  altogether,  or  promptly  rejects  it  as  soon  as  it  is  taken  into- 
the  mouth.  Hot,  sour  and  sweet  food  is  also  badly  borne,  but 
cool  milk  is  readily  swallowed,  and  in  this  fact  consists  the  pecu- 
liarity of  this  form  of  false  dysphagia,  the  true  cause  of  which 
may  be  easily  discovered  by  inspecting  the  mouth. 

In  other  cases  there  is  a  real  impossibility  of  swallowing  de- 
pending either  upon  diseases  of  the  throat  and  pharynx  or  upon 
stricture  of  the  oesophagus.  To  the  former  belong  all  acute  and 
subacute  cases  of  dysphagia,  to  the  latter,  chronic  ones. 

It  is  noteworthy  that  different  forms  of  catarrhal  and  fol- 
licular sore  throat  in  children  run  entirely  imperceptibly  in  this 
regard,  so  that  they  are  often  overlooked.  The  same  may  be 
said  of  many  cases  of  diphtheritic  and  of  scarlatinal  sore  throats- 
On  the  contrary,  difficult  deglutition  occurs  in  phlegmonous  an- 
ginas terminating  with  the  formation  of  an  abscess  of  one  of  the 
tonsils,  as  well  as  in  retro-pharyngeal  abscesses  and  in  severe 
cases  of  diphtheritic  and  scarlatinal  sore  throats.  A  simple  in- 
spection or,  in  the  case  of  an  abscess,  palpation,  make  the  diagno- 
sis of  all  these  morbid  forms  easy. 

Swallowing  of  soft,  as  w^ell  as  of  liquid,  food  sometimes 
causes  such  a  pain  that  the  child  entirely  refuses  any  food ;  such 
an  occurrence  frequently  happens  because  of  the  formation  of 
erosions  on  the  tonsils  after  sloughing  of  the  diphtheritic  mem- 
branes. 


SEMEIOLOGY    OF    DIFFICULT    DEGLUTITION  145 

Difficult  deglutition  accompanied  by  choking  due  to  fallinf 
ot  food,  or  water,  into  the  larynx,  and  by  regurgitation  of  the 
swallowed  fluid  through  the  nose,  depends  upon  paralysis  of  tJur 
soft  palate,  as  the  result  of  previous  diphtheria.  On  inspection 
the  mucous  membrane  of  the  fauces  appears  normal,  but  the  soft 
palate  remains  immobile  during  deep  inspiration  and  phonation, 
as  well  as  upon  touching  it  with  a  brush.  In  nurslings  regurgi- 
tation of  the  milk  through  the  nose  may  occur  even  without 
paralysis  of  the  soft  palate,  namely,  because  of  cleft-palate. 

Of  acute  oesophageal  diseases  creating  a  barrier  to  swallow- 
ing in  childhood,  there  occur:  CEsophagitis  corrosiva  (may  be 
recognized  from  the  history  and  presence  of  burns  in  the  mouth 
and  fauces),  soor  of  the  oesophagus  peculiar  to  children  exclu- 
sively during  the  first  days  or  weeks  of  life  from  a  neglected 
thrush,  and  spasm  of  the  cesophagus  in  older  children.  It  is  true 
that  we  do  not  find  in  text-books  on  Children's  Diseases  any  allus- 
ions to  the  fact  that,  besides  hydrophobia,  the  cause  of  the  com- 
plete impossibility  to  swallow  may  be  an  oesophageal  stricture  due 
to  spasm  of  the  oesophageal  muscles  ;  nevertheless  this  sometimes 
occurs,  as,  for  instance,  in  one  case  which  was  demonstrated  in 
my  clinic  in  November,  1889. 

A  girl,  seven  years  old,  previously  in  good  health,  but  rather 
thin  and  pale,  was  brought  to  the  clinic  on  account  of  complete 
inability  to  swallow.  The  disease  began  ten  days  before  by  lumps, 
of  hard  food  sometimes  stopping  in  the  oesophagus,  and  soon  re- 
turning to  the  mouth.  During  the  last  days  even  fluid  passed  with 
difficulty  and  produced  a  peculiar  rumbling  sound.  The  obstruc- 
tion was  sometimes  so  great  that  the  patient  could  not  even  swal- 
low a  teaspoonful  of  milk.  No  hindrance  was  found  on  examina- 
tion by  the  sound,  which,  provided  with  a  sponge  the  size  of 
a  walnut,  passed  very  freely,  and  after  that  the  patient  could 
drink  a  few  drops  of  water.  The  patient  was  given  sodium  bro- 
mide, and  a  week  later  it  was  found  that  the  difficult  deglutition 
had  disappeared  entirely. 

Here  the  quick  development  and  rapid  disappearance  of  the 
oesophageal  obstruction  determined  the  diagnosis.  Similar,  purely 
nervous  strictures  of  the  oesophagus,  are  sometimes  easily  recog- 
nized by  hard  food  passing  easier  than  liquids,  or  by  the  con- 
siderable variation  in  the  degree  of  the  stenosis.     Spastic  stric- 


146  SEMEIOLOGV    OF    DIFFICULT    DEGLUTITION 

ture  of  the  oesophagus,  like  other  neuroses,  particularly  occurs  in 
children  of  neuropathic  parents. 

Interference  with  swallowing;  due  to  obstruction  or  stricture 
of  the  oesophagus  is  characterized  by  the  food  or  water  being  kept 
in  the  oesophagus,  but  without  reaching  the  stomach,  and  soon  re- 
gurgitated unchanged.  That  the  regurgitated  food  does  not 
come  from  the  stomach  is  evident  by  the  absence  of  hydrochloric 
acid,  or  bile. 

(  )nc  mav  determine  with  the  sound  not  only  the  place  of 
stricture,  but  even  its  degree. 

The  most  frtxiuent  cause  of  (esophageal  strictures  in  chil- 
dren is  burning  of  the  oeso])hagus  with  some  caustic  substance 
(sul])huric  acid,  sodic  hydrate,  etc.),  usually  indicated  in  the 
historv.  The  stricture  appears  during  the  stage  of  cicatrization  of 
the  ulcerated  mucous  membrane,  gradually  increasing  for  several 
months. 

Cicatrizant  strictures  in  chiKlren  very  seldom  develop  from 
other  causes,  such  as,  for  instance,  sy]:»h.ilitic  ulcers,  injuries  result- 
ing from  swallowing  foreign  bodies,  small-])<>x  i)ustules,  etc.  Com- 
paratively more  frequent,  but  also  rarely,  (esophageal  stenosis 
arises  in  children  because  of  compression  from  tumors  of  the 
anterior  and  ])osterior  mediastina,  as,  for  instance,  caseous  degen- 
erated glands,  abscess  caused  by  vertebral  caries,  etc. 

In  other  cases  again  stenosis  of  the  oesophagus  i-s  an  inher- 
ited defect  of  development.  Then  we  have  to  contend  with  either 
the  formation  of  diverticula,  or  with  a  limited  contracture  of  the 
oesophagus.  In  the  former  case  the  sound  sometimes  glides 
freely  into  the  stomach,  but  again  stops  in  the  blind  sac  and  does 
not  go  any  farther.  When  particles  of  food  lodge  in  the  diver- 
ticulge,  they  remain  there  indefinitely,  being  regurgitated  later  in  a 
purulent  condition. 

When  the  oesophageal  stricture  is  congenital  the  sound  does 
not  always  detect  it  at  one  place  (this  becomes  gradually  normal), 
but  the  parents  notice  that  the  child  very  often  chokes  as  soon 
as  he  begins  to  eat.  as  if  he  had  tried  to  swallow  food  not  well 
masticated.  In  complete  inherited  obstruction  of  the  (Desophagus 
the  new-born  very  soon  (in  three  or  four  days)  dies  from  starva- 
tion, always  regurgitating  the  milk  which  they  apparently  swal- 
low ravenously. 


SEMEIOLOGY  OF  VOMITING. 

Vomiting  occurs  in  children  much  oftener  than  in  adults, 
appearing-  easier  the  younger  the  child.  During  the  first  months 
of  life  it  frequently  occurs  in  entirely  healthy  children  because 
of  overfeeding,  bearing  the  name  of  habitual  z'oiniting  or  eructa- 
tiuJK  The  latter  differs  from  real  vomiting  by  its  sudden  appear- 
ance in  a  perfectly  healthy  and  cheerful  child,  without  any  pre- 
monitions which  indicate  nausea,  \vithout  disfiguration  of  the 
face  and  without  any  exertion,  that  is,  no  contraction  of  the 
abdominal  muscles.  The  child  remains  after  the  eructation  as 
cheerful  as  he  was  before. 

Eructation  appears  especially  easy  in  a  child  immediately 
after  suckling,  if  he  is  carelessly  taken  in  the  hands  (compres- 
sion of  the  abdomen )  or  if  he  is  bounced.  On  the  contrary,  a 
real  vomiting  is  usually  preceded  by  a  nausea  which  makes  itself 
evident  in  a  nursling  b}-  the  face  grov/ing  pale,  by  general  rest- 
lessness, a  small,  quickened  pulse  and  frigidity  of  the  extremi- 
ties. The  vomiting  itself  occurs  with  the  aid  of  the  abdominal 
muscles ;  therefore,  the  contents  of  the  stomach  are  expelled  with 
considerable  force,  while  at  the  end  of  vomiting  the  patient  utters 
a  peculiar  sound  which  gives  the  impression  of  suffocation.  The 
peculiarity  of  the  milk  rejected  with  eructation  is  of  no  special 
value  in  a  differentiation  from  vomiting,  because  it  may  in  both 
cases  be  either  entirely  fresh,  or  coagulated,  depending  upon  the 
time  which  has  elapsed  since  nursing.  If  eructation  takes  place 
immediately  after  nursing,  then  the  milk  is  liquid,  however,  if 
some  time  after,  for  instance,  after  twenty  minutes,  then  it  is 
coagulated.  When  the  milk  is  thrown  out  uncoagulated,  not- 
withstanding a  sufficient  interval  of  time  after  suckling,  then  it 
denotes  insufficiency  of  acid  (or  rennet-ferment)  in  the  gastric 
juice,  so  that  such  a  vomiting  cannot  be  regarded  as  a  plain  eruc- 
tation, but  should  be  looked  upon  as  a  pathological  condition. 
The  same  may  be  said  regarding  a  considerable  amount  of  mucus 
mixed  with  the  eructated     milk,  as  well  as  regarding     vomitus 


148  SEMEIOLOGY    OF    VOMITING 

which  is  entirely  free  from  milk,  consisting  of  a  small  amount 
of  fluid  mixed  with  bile  (the  stomach  being  empty,  the  vomiting 
can  not  appear  as  eructation). 

Of  particular  value  is  vomiting  where  the  stomach-contents 
show  considerable  admixture  of  blood. 

Bloody  vomiting  in  children  occurs  very  seldom,  as  the 
common  causes  of  such  vomiting,  namely,  round  ulcer  of  the 
stomach,  cancer,  and  chronic  diseases  of  the  liver,  are  unusual 
in  childhood.  It  is  true  that  in  literature  a  few  cases  of  ulcer 
of  the  stomach  and  duodenum  are  described,  but  all  refer  to  chil- 
dren in  the  first  weeks  of  life.  These  maladies  sometimes  pro- 
duce in  the  new-born  bloody  vomiting  and  bloody  dejecta,  and 
the  loss  of  blood  is  usually  so  abundant  that  the  patients  die  in 
a  few  days  with  symptoms  of  acute  anaemia.  This  disease  is 
described  in  the  text-books  as  melccna  neonatorum,  cases  of  re- 
covery from  which  are  rare. 

Much  oftener  than  ulcers  of  the  stomach  as  a  cause  of  in- 
testinal and  gastric  haemorrhages  in  new-born  is  general  mal- 
nutrition manifested  during  life  by  debility  and  a  tendency  to 
bleeding  from  the  mucous  membranes  and  skin,  and  post-mortem 
by  haemorrhages  into  the  serous  cavities  and  parenchymatous  or- 
gans. 

The  aetiology  of  the  disease,  called  by  Grandidier  transitory 
hemophilia  of  the  new-born,  has  not  yet  been  definitely  deter- 
mined. 

There  may  be  included  here  cases  of  septicaemia  and  of  so- 
called  acute  fatty  degeneration  of  the  new-born  (Buhl),  and 
some  cases  of  inherited  syphilis,  syphilis  hcemorrhagica  neona- 
torum. 

Bloody  vomiting,  as  a  symptom  of  temporary  haemophilia,, 
differs  from  melaena  neonatorum  by  the  haemorrhages  appearing 
in  the  former  cases  not  only  from  the  gastro-intestinal  canal,  but 
also  from  various  organs,  and  this  fact  alone  suffices  for  the  diag- 
nosis of  temporary  haemophilia. 

According  to  the  frequency  of  occurrence  the  order  of  the 
haemorrhages  is  as  follows :  Umbilical,  gastro-intestinal,  from 
the  genito-urinary  organs,  from  the  mouth  and  nose,  the  con- 
junctivae, from  the  ears,  skin  and  kidneys. 

[An  interesting  case  of  conjunctival  haemorrhage  is  reported 


SEMEIOLOGY    OF    VOMITING  1 49 

by  Meyer  Wiener.*  The  haemorrhage  started  in  the  morning 
following-  birth ;  was  persistent  during  five  days  ;  and  ended  with 
death.  The  post-mortem  proved  negative.  Syphilis  and  gon- 
orrhoea was  discovered  in  the  history  of  the  mother.  The  cause 
was,  in  the  author's  opinion,  silver  nitrate  which  was  applied  to 
the  baby's  eyes  after  birth. — Earle.] 

The  haemorrhage  is  never  active  (arterial  umbilical  hsemt^r- 
rhage  cannot  be  included  here,  being  a  local  disease),  but  oozes 
from  the  healthy  mucous  membrane.  Haemorrhage  most  often 
appears  from  the  fifth  up  to  the  twelfth  day  of  life,  proving  very 
quickly  (in  from  three  to  five  days)  fatal.  Recovery  is  possible, 
but  seldom  occurs. 

[Abt**  classifies  the  haemorrhages  in  new-born  in  (i)  trau- 
matic or  accidental,  and  (2)  spontaneous.  Spontaneous  haemor- 
rhages are  very  seldom  met  with ;  one  case  in  500  or  700  births. 
Of  thirteen  reported  cases  in  ten  haemorrhage  developed  shortly 
after  birth,  two  were  a  few  weeks  old  and  one  five  and  one-half 
months.  Spontaneous  haemorrhage  should  be  regarded  as  a  symp- 
tom of  some  infection  and  as  an  indication  that  the  porosity  of 
the  vessel  walls  is  increased,  or  that  the  tendency  of  the  l:)lood 
to  clot  is  diminished.  Jacobi  claims  that  this  disease  was  very 
frequently  noted  when  puerperal  fever  was  of  common  occur- 
rence. Walls  observed  one  case  where  the  haemorrhage  was  due 
to  malarial  intoxication,  in  another  case  obstructive  jaundice  was 
the  cause  of  haemorrhage.  In  general,  says  Abt,  this  disease  may 
be  caused  by  a  number  of  different  conditions,  and  that  no  one 
causal  factor  is  responsible  for  the  haemorrhagic  diathesis  in 
infants. — Earle.  ] 

In  elder  children  also  bloody  vomiting  usually  appears  as 
a  symptom  of  temporary  haemophilia,  but  the  meaning  of  this 
condition  is  entirely  different  than  in  the  new-born,  inasmuch 
as  gastric  haemorrhage  occurs  in  older  children  most  often  in 
purpura  lueiiiorrhagica,  s.  morbus  maculosus  Werlhofii  (see 
Purpura)  and,  less  frequently,  in  the  prodromal  period  of  haemor- 
rhagic small-pox  (ibidem). 

In    diagnosticating     bloody     vomiting     one     should     bear 


*St.  Louis  Medical  Reviezv,  April  25,  1903. 

**Journal  Am.  Med.  Assoc,  Jan.  31,  1903.     (See  also  Abt's  Abstract  in 
The  Practical  Medic.  Series,  ed.  by  Abt,  June,  1903,  pp.  15.  16.) 


150  SEMEIOLOGY    OF    VOMITING 

in  mind  that  besides  real  h?ematemesis  there  is  alsa 
false  luonatciiicsis.  The  latter  is  nothing  but  vomiting  of 
the  swallowed  blood,  while  in  a  true  haematemesis  the  haemorrhage 
takes  place  from  the  mucous  membrane  of  the  stomach  itself. 

False  hsematemesis  in  nurslings  occurs  in  the  presence  of  fis- 
sures on  the  nipples  of  the  nursing  woman,  the  child  suckling 
the  blood  together  with  the  milk  (very  rare  cause)  :  or  there  is 
haemorrhage  from  the  mucous  membrane  of  the  mouth,  for  in- 
stance, after  cutting  the  frenulum  linguae,  or  after  operating  for 
hare-lip ;  according  to  Rilliet  and  Barthez  it  also  occurs  from 
swallowing  blood  during  the  confinement,  etc.  In  all  such  cases 
the  diagnosis  of  false  hrematemesis  is  based,  first,  upon  the  de- 
tection of  the  source  of  bleeding;  second,  upon  the  small  amount 
of  blood  in  the  dejecta,  and  third,  upon  the  condition  of  the  gen- 
eral nutrition,  which  scarcely  suffers  at  all  because  of  the  slight 
loss  of  blood  ;  while  in  true  haematemesis  the  child  is  always  very 
weak   and  ])ale. 

In  elder  children  the  most  frequent  cause  of  false  haemateme- 
sis is  epistaxis,  especially  when  occurring  in  the  recumbent  pos- 
ture. As  in  nose-bleeding  some  blood  always  appears  externally, 
this  symptom  alone  may  easily  determine  the  diagnosis. 

To  false  haematemesis  are  also  referred  cases  of  vomiting 
wherein  blood  is  mi.xed  with  the  voiuited  substance  as  streaks 
or  small  drops,  usually  thus  arising  from  the  fauces  because  of 
blood-stasis  during  the  act  of  vomiting.  Such  admixture  of  blood 
shows  only  that  the  act  of  vomiting  was  accompanied  by  great 
tension  of  the  abdominal  muscles. 

Haematemesis  is  sometimes  simulated  by  materials  which 
have  nothing  to  do  with  blood,  having  only  a  color  resemblance,, 
for  instance,  red  wine  taken  by  the  patient  shortly  before  vom- 
iting, drugs  containing  cochineal,  etc.  One  should  bear  in  mind 
all  these  possibilities  in  the  history  of  the  disease  before  real 
hsematemesis  is  diagnosticated.  In  case  of  doubt  a  microscopical 
examination  for  the  red  corpuscles  must  be  undertaken,  and  if 
the  latter  be  so  altered  by  the  gastric  juice  that  even  the  micro- 
scope does  not  decide  the  question,  then  it  remains  to  perform  the 
chemical  test  of  Heller,  which  is  recommended  for  haematuria 
and  is  based  on  the  following :  If  an  alkaline  fluid  containing 
blood  and  phospates  be  heated  then  a  deposit  of  bloody  pigment 


SEMEIOLO(iY    OF    VOMIYIXG 


151 


will  be  precipitated  and  become  stained  a  bright-red  color. 

One  proceeds  in  the  following  way :  The  vomitus  being 
mixed  with  a  weak  solution  of  sodic  hydrate,  is  filtered  and 
mixed  with  an  equal  volume  of  urine  (tliat  is,  with  a  liquid  con- 
taining phosphates)  and  is  then  boiled. 

Regarding  the  similarity  of  hsmatemesis  to  h?emoptysis, 
this  circumstance  cannot  be  of  great  value  in  childhood,  because 
haemoptysis  does  not  often  occur  in  children.  We  would,  how- 
ever, remark  that  blood  after  having  been  in  the  stomach  for 
awhile  differs  from  pulmonar_\-  blood  by  its  darker  color,  and  acid 
reaction. 

Diseases  in  which  a  common  vomiting  occurs  ma\'  be  divided 
into  two  groups,  depending  upon  whether  they  begin  with  high 
fever  or  run  with  normal  or  almost  normal  temperature. 

The  diagnostic  meaning  of  -c'oiiiifiis  in  acute  febrile  diseases 
will  be  diff'erent,  depending  upon  the  patient's  age.  In  small 
children,  two  or  three  years  of  age,  vomiting  which  occurred  only 
once,  accompanied  by  rapid  and  considerable  elevation  of  temper- 
ature, is  of  no  particular  value  in  a  diagnosis,  because  at  this  age 
vomitus  appears  during  any  febrile  disease,  whatever  the  cause 
of  elevation  of  the  temperature  up  to  39.5  degrees  to  40  degrees 
C.  (103  to  104  degrees  F.)  may  be.  The  matter  is  different  with 
vomiting  in  older  children  and  where  it  occurs  only  in  the  be- 
ginning of  a  few  diseases,  among  which  of  the  exanthemata, 
may  be  included  scarlet  fever,  small-pox  and  erysipelas,  and  of 
the  local  diseases,  inflammation  of  the  cerebral  meninges  and 
the  peritoneum.  These  diseases  must  be  considered  wdien  the 
physician  deals  with  a  child  older  than  three  years,  who  is  taken 
ill  with  violent  fever  and  vomiting.  In  the  beginning  of  other 
febrile  diseases  the  vomiting  is  caused  almost  exclusively  by  im- 
proper diet,  so 'that  it  will  be  of  value  in  the  diagnosis  of  the 
above-mentioned  diseases  onlv  when  it  appears  with  an  e)iipty 
stomach,  that  is,  if  the  patient  vomits  nnicous  fluid  mixed  with 
bile,  and  if  there  may  be  excluded  the  influence  of  different  drugs 
chief  of  which  are  the  more  recent  antipyretics,  as.  for  instance, 
antipyrine,  salicylate  preparations,  etc.  For  diagnostic  purposes, 
and  in  view  of  all  these  antipyretics  being  useless  in  their  influence 
upon  the  morbid  process  itself   (the  brief  lowering  of  tempera- 


152  SEMEIOLOGY    OF    VOMITING 

ture  is  not  of  much  use),  it  is  very  desirable  that  the  physician 
should  not  be  too  hasty  in  administering  medicines. 

V'omiting  with  fever,  or  with  slight  elevation  of  tempera- 
ture, occurs  in  various  diseases.  For  the  correct  estimation  of 
vomiting  one  must  first  of  all  intiuire  whether  it  arises  after 
coughing,  or  without  the  latter. 

Vomiting  after  coughing  most  often  occurs : 

(1)  in  pertussis  (whooping  cough),  but  not  exclusively 
here. 

(2)  Jn  dr\  pharyngitis,  when  the  mucous  membrane  is  in 
such  a  condition  of  hyperesthesia  that  a  few  coughing  spells 
are  sufficient  to  produce  vomiting  by  refiex  action  upon  the  fauces. 

(3)  In  chronic  hyperplasia  and  caseous  degeneration  of 
the  bronchial  glands. 

(4)  In  bronchitis  due  to  cold  if  it  develops  in  a  child  which 
recently  had  whooping  cough ;  finally,  in  a  suffocating  cough 
occurring  sometimes. 

(5)  In  hrmichiectasicr  with  abundant,  but  tenacious  spu- 
tum. 

(6)  In  purulent  pleuritis  opening  into  the  bronchi. 
Briefly  speaking,  the  diagnosis  of  these  cases  is  not  difficult. 

The  two  latter  conditions  may  be  determined  by  means  of  phys- 
ical examination  (see  the  corresponding  sections)  ;  the  former 
ones  differ  from  each  other  by  the  course  and  the  character  of 
the  cough  (see  the  part  on  \Miooping  Cough),  although  they 
may  give  negative  results  on  percussion  and  auscultation. 

Vomiting  at  the  end  of  the  coughing-spell  has  a  particularly 
important  bearing  upon  the  diagnosis  of  whooping  cough  in 
nurslings.  It  frequently  exists  without  the  characteristic  whistle, 
but  attended  with  vomiting,  while  another  kind  of  cough  which 
would  produce  vomiting  almost  never  occurs  in  this  age. 

A  febrile  vomiting,  independent  of  cough,  occurs  either  be- 
cause of  irritation  of  the  gastric  mucous  membrane,  or  reflexly 
from  the  affection  of  other  organs,  or  from  general  intoxication 
of  the  organism  (blood-poisoning). 

Gastric  vomiting  which  depends  upon  introducing  irritant 
substances  into  the  stomach,  whatever  they  may  be,  indigestible 
food  or  simply  emetic  remedies,  is  characterized  by  not  being 
associated  with  any  other  symptoms,  as  well  as  by  the  absence 


SEMEIOLOGV    OF    VOMITING  I53 

•of  any  bad  sequelae.  The  child  remains,  after  such  a  vomiting, 
•entirely  healthy  and  even  does  not  lose  his  appetite.  In  other 
cases  gastric  vomiting  is  only  one  of  the  symptoms  of  an  affection 
of  the  stomach,  as  dyspepsia  or  catarrh  (see  the  corresponding 
•description). 

As  a  result  of  some  neurosis  (hyperaisthesia)  of  the  stomach, 
vomiting  sometimes  occurs  simply  because  of  general  nervous- 
ness and  chlorosis,  as,  for  instance,  in  the  following  case : 

A  girl,  eleven  years  of  age,  previously  in  good  health,  en- 
tered the  hospital  on  account  of  daily  vomiting,  which  had  ex- 
isted interruptedly  during  the  past  two  months.  She  never  vom- 
ited when  the  stomach  was  empty,  but  always  after  meals,  solid 
ras  well  as  fluid  ones.  Before  vomiting  the  patient  had  suffered 
•during  the  whole  preceding  month  from  singultus  (hiccough). 
The  parents  claimed  that  she  had  moved  the  bowels  not  more 
ithan  four  times  during  the  last  two  months.  When  the  patient 
■entered  the  hospital  she  was  not  emaciated  at  all,  but  somewhat 
pale  and  weak.  Record:  She  can  walk  now  about  a  mile,  but 
before  she  became  sick  she  was  much  stronger  and  with  better 
.nourishment.  The  tojigiie  is  clean;  the  appetite  not  bad;  the 
thirst,  normal ;  the  epigastrium  not  distended  and  painless  upon 
pressure;  the  abdomen  is  distended  considerably,  but  is 
painless  without,  as  well  as  upon  pressure;  no 
tumor  is  palpable ;  the  bowels  seem  to  have  been 
constipated  for  about  ten  days ;  neither  fever,  nor  cough ;  the 
-sleep,  good ;  tape-worms  were  absent ;  temperature  ^^y  degrees 
■C  (98.6  degrees  F.)  ;  pulse  88,  regular;  urine  without  albumen. 
During  the  first  day  in  the  hospital  she  vomited  twice,  in  the 
■morning  after  a  few  tablespoons  of  soup  and  in  the  afternoon 
after  tea ;  the  vomiting  occurs  easily,  without  any  eff'ort.  After 
•supper  (a  few  spoons  of  gruel)  there  was  no  vomiting.  On  the 
second  day  the  vomiting  again  took  place  twice ;  the  third  day,  no 
vomiting ;  a  spontaneous  movement  of  the  bowels,  very  dense 
•dejecta.  Up  to  the  tenth  day  there  was  one  more  defecation;  the 
xvomiting  did  not  occur  every  day.     She  was  given : 

Tr.  quin.  comp.  3^8, 

Fowler's  sol.  mxx. 

Sig.     Twenty-five  drops  before  dinner  and  supper. 


154  SEMEIOLOr.Y    OF    VOMITING 

After  one  day  the  vomiting  and  constipation  disappearecT. 
and  did  not  reappear  even  when,  a  week  later,  the  arsenic  was 
stopped.  Several  months  later,  the  patient  entered  the  hospital 
again  on  account  of  vomiting,  but  arsenic  did  not  help  this  time. 
The  patient  was  soon  taken  away  by  her  parents  and  her  further 
history  is  unknown. 

The  question  whether  we  had  to  do  in  this  case  with  t'o;;/- 
ifing  from  simulation  remained  unsolved.  The  ease  with  whicli 
vomiting  took  ])lace  after  the  smallest  quantities  of  food  allowed 
the  supposition  that  the  patient  threw  out  the  food  without  swal- 
lowing it,  but  observation  cHd  not  ccMifirm  this  opinion. 

Henoch  f)l)serve(l  vomiting  caused  b\'  lixj^era^sthesia  of  the 
stomach  (vomitus  nervosus),  especially  in  nervous  children,  in 
the  mornings  after  hasty  eating.  In  two  cases  vomiting  occurred 
also  in  the  later  day-time  in  a  boy  of  seven  years  and  in  a  girl 
eight  years  old,  but  always  after  some  nervous  excitement.  Such 
vomiting  with  intervals  of  several  days  lasted  months  without 
any  further  conse(|uences.  and  then  stopped  entirely  either  spon- 
taneously, or  under  the  influence  of  tonic  treatment. 

The  diagnosis  of  the  nervous  origin  of  vomiting  is  based 
especially  on  the  possibility  of  excluding  diseases  of  the  stomach 
and  of  other  organs,  upon  which  vomiting  may  depend.  Nervous 
vomiting  is  often  characterized  by  its  obstinateness  and  easy 
occurrence,  often  without  nausea,  and  by  its  continuation  being  in 
contrast  with  the  good  appetite  and  relatively  good  general  con- 
dition of  the  nutrition.  This  is  at  least  correct  for  childhcKxl. 
We  have  observed  a  few  cases  of  nervous  vomiting  in  boys,  as 
well  as  in  girls,  who  suffered  from  daily  vomiting  during  several 
months  in  succession,  and  who  nevertheless  did  not  grow  thin ; 
but  in  adults  this  symptom  is  more  dangerous,  because  women 
sometimes  fall  into  the  most  dangerous  degrees  of  marasmus  as: 
the  result  of  vomiting. 

Reflex  vomiting  is  most  often  caused  by  irritation  of  the 
bowels,  peritoneum  or  brain.  Vomiting  niay  accompany  an}-  sci'cre 
pain  in  the  abdomen,  whether  this  be  of  nervous  origin  (colics),  or 
inflammatory  ;  and  further  by  any  obstinate  constipation,  especially 
because  of  intestinal  obstruction  and  when  uncontrollable  finally 
becomes  of  fcccal  character  (if  not  b}'  its  aspect,  at  least  by  the- 
odor) . 


sKMF.ioLocv  OF  N'oMiri xc; 


155 


Vomiting;  is  also  sometimes  caused  by  intestinal  worms.  The 
latter  cause  may  be  suspected  onlv  when  the  jiatient  complains  of 
nausea,  particularly  with  an  em])ty  stomach,  while  taking  fcxjd 
not  onl}'  docs  not  cause  vomiting,  but  even  prevents  it  bv  remov- 
ing the  nausea.  The  diagnosis  of  ta])e-worm  becomes  completelv 
confirmed  if  the  microscopical  examination  of  the  dejections  de- 
tects there  the  presence  of  ova,  from  the  character  of  which  the 
species  of  the  parasite  may  be  determined.  1  besides  this  method, 
the  diagnosis  of  intestinal  parasites  may  be  absolutely  established 
by  still  another  symptom,  namely,  by  the  elimination  of  the  ])ara- 
sites  or  their  segments  with  the  dejecta. 

Cerebral  vomiting  accompanies  acute,  as  well  as  chronic, 
diseases  of  the  brain  and  its  membranes.  Many  authors  lay  spe- 
cial stress  upon  the  character  of  the  vomiting ;  they  claim  that 
gastric  vomiting  dififers  from  cerebral  by  the  former  being  pre- 
ceded by  nausea  occurring  soon  after  taking  food,  while  cerebral 
vomitus  appears  without  nausea,  suddenly,  as  if  the  patient  ex- 
pectorates the  contents  of  the  mouth,  but  not  those  of  the  stom- 
ach, h^urthermore,  cerebral  vomiting  is  peculiar  by  often  appear- 
ing when  the  stomach  is  empty,  especially  after  changing  the 
horizontal  posture  for  the  vertical  one.  The  above  said  symp- 
toms must,  of  course,  be  taken  into  consideration  when  the  diag- 
nosis of  cerebral  vomiting  is  made,  but  they  have  no  decided 
value  at  all,  because  exceptions  are  met  with  in  both  directions ; 
that  is,  on  one  hand  it  is  not  always  easy  to  note  nausea  even  in 
gastric  vomiting,  which,  like  the  cerebral,  also  sometimes  arises 
from  changing  the  horizontal  posture  for  the  vertical  one ;  and 
on  the  other  hand,  it  is  undoubted  that  cerebral  vomiting  very 
often  arises  after  taking  food  or  drinks  and  especially  after  taking 
medicine.  Of  great  significance  in  the  diagnosis  of  cerebral  vom- 
iting is  its  persistence;  it  does  not  yield  for  several  days  either 
to  the  diet,  or  to  medicines ;  as  well  as  to  the  fact  that  the  patient 
feels  partially  and  sometimes  completely  relieved  after  gastric 
vomiting,  while  after  the  cerebral  variety  he  feels  still  more  weak- 
ened. Further  in  favor  of  cerebral  vomiting  are  :  the  clear  tongue, 
normal  stools  (or  constipation),  absence  of  bad  odor  from  the 
mouth,  painfulness  upon  pressure  in  the  epigastrium  and  of 
meteorismus,  violent  headaclie  (  whicli.  however,  is  far  from  being 
present  as  such  in  all  cases  at  the  beginning  of  tubercular  men- 


156  SEMEIOLOGY    OF    VOMITING 

ingitis),  somnolence  and  irregular,  retarded  pulse.  Generally 
speaking,  no  one  of  the  enumerated  sym.ptoms  may  be  regarded 
as  absolutely  certain,  and  each  one  taken  separately  may  be  absent, 
therefore"  the  complexity  of  symptom?  exhibited  is  of  the  most 
important  significance. 

In  some  cases  vomiting  is  necessarily  preceded  for  several 
hours  by  violent  headache,  diffuse  or  unilateral,  but  after  vomit- 
ing the  patient  falls  deeply  asleep  and  awakes  entirely  well.  Sim- 
ilar attacks  are  repeated  either  once  a  week,  or  at  greater  inter- 
vals, for  instance,  once  a  month,  or  two  to  three  times  a  year, 
depending  upon  migraine  which  occurs  in  children  from  seven  to 
ten  years  of  age,  although  not  sparing  even  children  of  the  first 
years  of  life.  Infantile  migraine  is  usually  accompanied  by  the 
face  growing  pale,  sometimes  by  a  somewhat  retarded  pulse  and 
even  by  slight  elevation  of  temperature,  so  that  the  physician,  if 
he  does  not  know  the  anamnesis  (as  w'ell  as  in  the  case  of  the 
first  attack  of  migraine),  may  suppose  the  beginning  of  acute 
hydrocephalus ;  but  the  question  becomes  determined  very  soon, 
of  course,  because  the  child  appears  entirely  well  after  sleep.  The 
similarity  with  the  cerebral  form  is  still  greater  when  repeated 
vomiting  occurs  during  migraine,  while  sleep  occurs  very  quickly. 

As  an  example  of  vomiting  due  to  blood-poisoning  may  be 
that  which  occurs  after  the  subcutaneous  injection  of  apomor- 
phine.  To  the  same  category  is  referred  nrccmic  vomiting  during 
acute  or  chronic  nephritis,  and  vomiting  from  chloroform.  In 
diagnosticating  the  latter  one  should  bear  in  mind  that  it  some- 
times persists  for  a  couple  of  days  after  the  operation  without 
yielding  to  any  remedies.  (I  would  point  out,  by  the  way,  that 
to  prevent  such  vomiting  one  should  try  change  of  air,  for  in- 
stance, transfer  the  patient  from  the  hospital  to  a  private  house ; 
cases  are  known  wherein  this  measure  had  a  magic  influence  on 
the  vomiting.) 

[In  American  literature  there  have  been  described  a  few 
cases  of  the  so-called  cyclic  or  recurrent  vomiting.  This  form 
usually  does  not  depend  upon  any  digestive  disorder,  being  un- 
accompanied by  pain ;  and  by  this  peculiarity  cyclic  vomiting 
differs  from  that  occurring  in  tabes  dorsalis,  neuroses  of  the  stom- 
ach and  hyperchlorydria.  The  vomiting  arises  either  suddenl}-, 
or  is  preceded  by  a  short  prodromal  period  consisting  of  general 


SEMEIOLOGY    OF    VOMITING  1 57 

malaise,  headache  and  anorexia.  In  the  beginning  the  vomited 
material  is  composed  of  food  particles,  later  on  of  sero-mucous 
fluid,  and  finally  of  blood.  At  the  same  time  constipation  is  ob- 
served, as  well  as  fever,  which  conditions  lead  to  exhaustion.  The 
paroxysm  of  vomiting  usually  stops  suddenly,  the  recovery  be- 
ing rapid.  Death  may  occur  from  collapse.  The  intervals  be- 
tween the  attacks  are  indefinite.  The  vomiting  is  believed  to  be 
due  to  elimination  by  the  stomach  of  some  poison  which  irritates 
the  mucous  membrane  of  that  organ  (Hand).*  These  poisons 
are  probably  due  to  faulty  metabolism (C.  Ely),**  occurring  most- 
ly in  gouty  and  neurotic  children.  According  to  Edsall***  recur- 
rent vomiting  is  caused  by  an  excessive  amount  of  acids,  his  view 
being  corroborated  by  the  fact  that  a  rapid  improvement  sets  in 
under  the  influence  of  an  alkaline  treatment  (which  must  be  car- 
ried out  energetically,  a  hundred  grains  of  bicarbonate  of  soda 
being  the  small  average  quantity,  daily,  at  the  commencement  of 
the  treatment).  In  the  urine  of  such  patients  indican  was  found 
(Griffith)****  and  also  aceton  (Edsall,  Marfan)  ;  the  latter,  ac- 
cording to  Marfan,  causes  the  vomiting  (the  result  of  acet- 
onaemia),  so  that  recurring  vomiting,  provided  Marfan's  view 
is  correct,  may  be  included  in  the  group  due  to  blood-poisoning, 
— Earle.] 

Leyden  describes  voniitijig  due  to  irritable  zveakness.'^^**'^  In 
his  opinion  this  nervous  vomiting  is  the  consequence  of  hyperaes- 
thesia  of  the  stomach  in  weakened  and  highly  irritable  persons 
recovering  from  severe  diseases.  According  to  his  observations 
this  vomiting  is  one  of  the  most  formidable  forms,  because  it  is 
sometimes  very  violent,  thus  being  dangerous  to  life.  Such  a 
vomiting  is  often  accompanied  by  convulsive  singultus.  The 
cause  may  be  some  dietetic  fault,  or  some  drug  (in  Leyden's 
case — antipyrin) . 

Leyden  regards  this  vomiting  especially  dangerous  in  the 
period  of  recovery  from  cerebro-spinal  meningitis,  typhoid  and 
diphtheria.     In  typhoid  fever,  Leyden  observed  attacks  of  severe 


*Proc.  Pliila.  Co.  Med.  Soc,  September,  igo2. 
**Jour.  Anier.  Med.  Assoc.,  March  28,  1902. 
***Amer.  Jour,  of  Med.  Sci.,  April,  1903. 
****Amer.  Journ.  of  Med.  Sciences,  November,  1900. 
*****Leyden:  Zeitschr  f.  Klin.  Medic,  XII.,  4  Heft. 


158  SKMEIOLOGV    OF    N'OMITING 

vomiting  during  the  treatment  with  baths,  with  the  cessation  of 
which  the  vomiting  stopped. 

Nervous  vomiting  in  convalescents  from  (Hphthcria  mu.'tt  be 
especially  mentioned,  because  it  occurs  in  childhood  much  oftener 
than  after  other  acute  diseases,  depending,  i^robably.  upon 
paralysis  of  the  vagus.  We  have  observed  it  only  after  grave 
forms  of  diphtheria.  It  is  usually  preceded  by  paral\sis  of  the 
soft  palate,  weakness,  or  irregularity,  and  retardation  of  the 
pulse.  Shortly  before  vomiting  the  patient  begins  to  complain 
of  severe  abdominal  pains  which  last  either  a  few  minutes,  or 
from  two  to  three  hcnirs.  After  the  vomiting  there  sets  in  con- 
siderable cardiac  collapse  ( feeble,  sometimes  irregular,  pulse, 
dilation  of  the  right  heart,  enlargement  of  the  liver  because  of 
passive  hvperccmia,  diminution  of  the  amount  of  urine,  albuminu- 
ria). The  patient  may  die  on  the  very  first  day  from  cardiac 
])aral\sis.  but  death  occurs  oftener  on.  the  second  or  third  day. 
Recovery  is  possible,  but  seldcjm  follows,  therefore,  such  a  symp- 
tom-complex as  ^ccakncss  of  the  heart,  abdominal  pains  and  vom- 
iting, in  the  jiericMJ  of  recovery,  must  be  regarded  as  very  omin- 
ous. 

From  vomiting  there  must  be  ditTerentiated  regurgitation  of 
fcx>d  or  drinks  which  did  not  reach  the  stomach,  being  observed, 
first,  in  strictures  of  the  oesophagus  and,  second,  during  paralysis 
■of  the  soft  palate. 

OBsophageal  sfrieture  develops  in  childhood  almost  exclu- 
sively after  burns  with  hot  water  or  caustic  substances,  for  in- 
stance, sulphuric  acid,  which  is  often  used  in  households  to  pre- 
vent window-panes  from  frosting. 

The  diagnosis  is  not  difficult,  the  impossibility  of  swallow- 
ing hard  food  or  considerable  quantities  of  fiuid,  with  the  his- 
tory, is  entirely  sufficient ;  the  place  and  degree  of  contracture  are 
determined  b}'  the  stomach  sound. 

Paralysis  of  the  soft  palate  develops  after  diphtheria  (his- 
tory) and  manifests  itself  by  the  fact  that  the  patient  suddenly 
■chokes  when  swallowing  food,  or  drinking,  and  forces  the  food 
out  through  the  mouth  or  nose ;  the  patient's  voice  assumes  a 
nasal  twang;  on  inspecting  the  throat  it  is  easily  noticed  that 
the  soft  palate  is  immovable  during  phonation  and  during  its 
irritation  bv  tickling  with  the  end  of  the  sound. 


DISEASES    OF   THE   STOMACH   AND    IN- 
TESTINES. 

.ACUTE  DISEASES  OF  THE  STOMACH  AND  INTESTINES  IN   NURSLINGS. 

Acute  disorders  of  digestion  in  nurslings  occurs  in  three 
chief  forms,  known  under  the  names  of  dyspepsia,  catarrh  of  the 
small  intestines,  and  follicular  enteritis,  or  catarrh  of  the  large 
bowels. 

The  first  form — dyspepsia — is  dependent  upon  the  mucous 
membrane  of  the  stomach  and  intestines  being  irritated  by  the 
products  of  the  fermentation  of  food  not  entirely  digested.  The 
disorder  of  digestion  does  not  depend  here  upon  some  gross 
anatomical  changes  of  the  mucous  membrane,  but  simply  upon 
the  inefficient  activity  of  the  gastric  juice.  At  any  event,  it  is 
impossible  to  mark  a  sharp  boundary  between  dyspepsia  and 
-catarrh  of  the  stomach. 

The  anatomical  feature  of  the  second  form  consists  in 
catarrh  of  the  mucous  membrane  of  the  small  intestines ;  and 
that  of  the  third  form  in  inflammation  of  the  mucous  membrane 
of  the  large  intestines,  with  special  lesions  of  the  follicles. 

The  differential  diagnosis  of  all  these  diseases  is  based,  first, 
upon  the  character  of  the  dejections  and,  second,  on  the  concom- 
itant appearances.  In  analysing  the  child's  dejections  it  is  nec- 
•essary  to  pay  attention  to  their  iiiiiiiber  during  twenty-four  hours  ; 
•their  consistency,  color,  odor  and  casual  admixtures. 

A  healthy  nursling,  when  the  stomach  is  normal,  moves  the 
bowels  two  or  three  times  in  twenty-four  hours.  The  fasces  are 
of  pap-like  or  jelly-like  consistency,  do  not  contain  a  superfluity 
of  water,  that  is,  normal  fgeces  should  wet  the  diaper  approx- 
imately as  one  centimeter  of  fluid.  The  more  water  in  the  dejec- 
tions, the  wider  becomes  the  circumference  of  the  soiled  swaddle. 
Further,  normal  stools  are  of  an  equally  bright-yellow  or  orange 
<:olor.  being  of  faint,  not  repugnant,  sourish  smell.  The  reaction 
is  faintly  acid,  and  they  usually  contain,  a  noticeable  admixture  of 


l6o  DISEASES  OF  THE  STOMACH  AND  INTESTINES 

mucus,  which  is  intimately  blended  with  the  faeces  and  does  not 
appear  in  the  form  of  separate  lumps  or  "nests,"  as  in  follicular 
enteritis. 

Dyspeptic  stools  exhibit  the  following  peculiarities :  They 
are  abundant,  but  not  frequent  (instead  of  two  or  three  times 
the  child  moves  the  bowels  about  five  times  in  twenty-four  hours) 
and  consist  especially  of  faeces;  the  amount  of  water  in  them  if* 
not  increased  ;  therefore,  their  consistency  remains  as  normal  jelly- 
like; the  amount  of  mucus  is  somewhat  increased,  but  this,  as 
in  normal  stools,  is  intimately  mixed  with  faeces,  yet,  if  it  occurs 
in  separate  lumps,  then  it  shows  irritation  of  the  large  bowels^ 
and  hence  the  transformation  of  dyspepsia  into  follicular  enteritis. 
Especially  characteristic  of  dyspepsia  is  the  presence  in  the  stools 
of  great  quantities  of  undigested  milk,  in  the  form  of  coagulcE,. 
which  consist  especially  of  fat,  salts  of  fatty  acids,  epithelium 
and  casein.  Furthermore,  the  alteration  of  the  color  is  also  char- 
acteristic ;  bilirubin  becomes  easily  transformed  during  dyspepsia 
into  biliverdin,  so  that  the  yellow  color  of  the  stools  appears 
mixed  with  green.  The  mixture  of  yellow,  green  and  white 
colors  give  to  the  stools  a  peculiar  aspect  which  justifies  its  com- 
parison with  "scrambled  eggs."  In  chronic  cases,  especially  in 
bottle-fed  children,  the  stools  appear,  because  of  lack  of  bile- 
pigments,  pale-yellow  or  even  colorless  altogether. 

The  odor  and  the  reaction  of  dyspeptic  dejections  usually 
are  faintly  or  strongly  acid ;  in  neglected  cases  foetid  dejections 
are  also  met  with. 

The  act  of  defecation  is  performed  easily,  frequently  with 
noise,  because  of  the  passage  of  flatus,  but  without  tenesmus  and 
pain. 

Dyspepsia  also  manifests  itself  by  vomiting,  meteorismus 
and  colicky  attacks.  Dyspeptic  vomiting  usually  occurs  after 
meals,  sometimes  immediately,  and  in  other  cases  one-fourth  to 
one-half  hour  after  meals,  accompanied  by  nausea  and  restless- 
ness, by  which  it  differs  from  eructation. 

Meteorism  and  colics  depend  upon  the  accumulation  of  gases 
in  the  bowels,  the  product  of  fermentation  of  undigested  food. 
The  attacks  of  colic  consist  in  periodically-occurring  abdominal 
pains.    Fever  is  absent  in  dyspepsia. 

If  the  diagnosis  of  dyspepsia  is  established  on  the  ground 
of  the  above-mentioned  symptoms,  only  half  the  matter  is  settled. 


DISEASES  OF    THE  STOAIACII   AM)    INTESTINES  lOI 

because  it  still  remains  to  determine  the  cause,  otherwise  the 
treatment  cannot  be  successful.  All  causes  of  dyspepsia  may  be 
included  in  the  irregular  diet.  In  breast-fed  children  overfeeding 
is  the. most  frequent  cause  of  dyspepsia;  either  the  child  is  given 
the  breast  oftener  than  every  two  hours,  or  the  baby  is  allowed 
to  nurse  more  than  fifteen  minutes,  or  he  is  fed  many  times  suc- 
cessively from  the  same  breast,  while  the  breasts  should  be  given 
alternately. 

Especially  often  do  children  of  young,  strong  mothers  rich 
with  milk,  but  with  weak  breasts,  suffer  from  dyspepsia,  (the 
milk  spouts  from  a  feeble  breast  by  several  streams,  even  when 
slightly  pressed  by  the  fingers ;  on  the  contrary,  from  a  firm 
breast  the  milk  is  more  difficult  to  be  sucked  or  pressed  out). 
Furthermore,  the  cause  of  dyspepsia  may  be  spoiled  milk,  re- 
sulting from  the  influence  of  indigestible  and  slightly  nutritive 
food  (fish-meals),  as  well  as  of  sour  fruits,  menstruation  and 
mental  excitement.  The  quality  of  the  milk  may  also  be  in- 
fluenced by  the  age  of  the  mother  { under  twenty  and  after  forty 
years)  and  the  condition  of  health  of  the  nursing"  woman,  as 
well  as  the  time  elapsing  since  the  confinement  (new-born  chil- 
dren often  fall  ill  with  dyspepsia,  if  the  nurse  feeds  them  with 
old  milk). 

The  causes  of  dyspepsia  in  bottle-fed  children  are  so  numer- 
ous and  various  that  only  the  most  important  can  be  pointed  out ; 
cow's-milk  of  poor  quality  (besides  the  admixture  the  care  of 
the  cow  may  be  of  significance),  especially  when  it  has  turned 
sour  or  if  it  be  diluted  insufficiently  with  water,  and  if  it  is  given 
with  some  admixtures  which  do  not  correspond  to  the  child's  age. 
So,  for  instance,  it  may  be  held  as  proven  that,  for  children  under 
three  or  four  months  of  age,  neither  starch,  nor  cocoa,  nor  dif- 
ferent kinds  of  coffee  are  good.  I  shall  not  refer  to  the  diagno- 
sis of  all  these  causes,  because  they  are  based  siniplv  on  the  his- 
tory. 

Some  authors  describe  still  another  form  of  dyspepsia  char- 
acterized by  the  appearance  of  dejections  very  rich  with  fat  and 
known  under  the  name  of  fatty  diarrha-a.  first  described  by 
Demme  and  Biedert.  This  disease  is  always  obstinate  and  may 
be  cured  only  by  administering  food  poor  in  fat.  According  to 
Biedert,  chemical  determination  in  percents  of  the  fat,  contained 


l62  DISEASES  OF  THE  STOMACH   AND  INTESTINES 

in  the  dry  remains  of  the  fseces,  is  required  for  the  exact  diag- 
nosis. The  percentage  of  fat  in  fatty  diarrhoea  varies  from  41 
to  47,  while  in  normal  stools  from  4  to  25.  For  practical  pur- 
poses one  may  content  himself  by  a  superficial  microscopical  ex- 
amination ;  a  small  particle  of  the  dejection  is  diluted  with  a  drop 
of  water  on  the  slide  and  examined.  In  normal  stools  there  ap- 
pears in  the  field  of  vision  of  the  microscope  only  small  drops  of 
fat,  and  in  very  small  amount,  while  in  fatty  diarrhoea  the  entire 
field  of  vision  is  occupied  b>-  large  drops  of  fat  or  crystals  of  fatty 
acids  and  salts. 

More  recently  Uffelmaun  and  Tchernofif  have  shown  that 
considerable  increase  of  fat  in  dejections  occurs  in  any  dyspepsia, 
so  that  one  cannot  be  guided  by  this  sign  in  the  diagnosis  of 
fatty  diarrhoea,  and  thus  the  existence  of  fatty  diarrhoea,  as  an 
independent  form  of  dyspepsia,  cannot  be  held  as  proven. 

In  ACUTE  CATARRH  OF  THE  SMALL    INTESTINES  the  dcjCCtionS 

are  abundant,  as  in  dyspepsia,  but  at  the  same  time  more  frequent 
(six  or  seven  times  during  twent}-four  hours)  and  liquid,  be- 
cause water  prevails  over  other  constituents.  They  are  water- 
ish,  pale,  and  discharged  as  a  strong  stream  with  noise  from  the 
eliminated  gases.  The  abdomen  is  usually  distended,  but  painless 
on  pressure.     Fever  is  absent. 

If  the  stomach  is  simultaneously  affected,  vomiting  appears. 
Such  varieties  of  gastro-entcntis  form  the  transition  from  a  simple 
catarrh  of  the  small  intestines  into  infantile  cholera,  known 
also  under  the  name  of  summer  complaint. 

Four  conditions  play  the  chief  role  in  the  aetiology  of 
INFANTILE  CHOLERA:  (i)  age  Under  one  year;  (2)  bottle-feed- 
ing;  ( 3 )badly- ventilated  rooms,  and   (4)   summer  heat. 

[Cotton*  says  that  statistics  indicate  that  in  fatal  cases  of 
summer  diarrhoea  less  than  3  per  cent  were  exclusively  breast- 
fed. No  clinical  phase  of  this  subject  begins  to  rival  in  import- 
ance the  one  fact  that  summer  diarrhoea  with  rare  exceptions 
means  practically  summer  artificial  feeding. — Earle.] 

[Martin  is  inclined  to  see  in  the  common  house-fly  the  cause 
of  summer  diarrhoea ;  "Each  succeeding  year  confirms  my  obser- 
vation of  1898  that  die  annual  epidemic  of  diarrhoea  and  of 
t}"phoid  is  connected  with  the  appearance  of  the  common  house- 


*Joui:  Am.  Med.  Assn.,  June  13,  1903,  p.  1644. 


UISEASKS  OF  TIIK  SIOMACH   AND   INTES'll  N' KS  163 

fly,  which  becomes  very  numerous  at  the  beginniii"^  of  July,  and 
breeds  chiefly  in  privy-vaults.  The  increase  and  decrease  of  the 
annual  diarrhoea  and  typhoid  epidemic  can  be  foretold  with  a 
great  degree  of  accuracy,  an  increase  in  the  diarrhcea  cases  oc- 
curring in  a  week,  and  typhoid  notifications  in  three  or  four  weeks 
after  an  increase  in  the  number  of  flies  is  observed.  The  annual 
epidemics  of  these  two  diseases  begin  and  end  with  the  appear- 
ance and  disappearance  of  the  domestic  fly."'* — Earle.] 

In  a  pathologico-anatomical  sense  cholera  is  nothing  but  a 
very  acute  catarrh  of  the  whole  gastro-intestinal  canal,  of  course 
■of  mycotic  origin  although  the  specific  microbe  has  not  yet  been 
found.  It  is  probable  that  infantile  cholera  is  produced  by  various 
•saprophytic  bacteria. 

[Shiga's  bacillus  is  held  by  some  authors  as  the  most  com- 
mon cause  of  summer  diarrhoea.  Duval  and  Bassett**  isolated  this 
micro-organism  from  the  stools  of  forty-two  children  suffering 
from  this  disease.  They  did  not  find  the  bacillus  in  the  stools 
of  healthy  children,  or  those  suffering  from  a  simple  diarrhoea 
or  other  affections.  Gray  and  Knox***  also  reached  the  con- 
clusion that  Shiga's  bacillus  is  the  cause  of  most  cases  of  sum- 
mer diarrhoea  among  children.****  Knox  says :  "There  is  good 
reason  for  the  confidence  that  a  proportion,  and  probably  a  large 
one,  of  the  so-called  summer  diarrhoeas  of  infancy  is  caused  by 
the  bac.  dysenterice  (Shiga). — Earle.] 

The  infectious  origin  of  infantile  cholera  is  evident  from  and 
the  sudden  beginning  of  the  disease,  sometimes  with  high  fever ; 
and  the  rapid  occurrence  of  collapse  and  death,  without  any  corre- 
spondence to  the  number  and  quality  of  the  dejections. 

Clinically,  infantile  cholera  manifests  itself  like  the  epidemic 
variety,  by  a  severe  and  persistent  vomiting,  violent  diarrhoea 
and  quick  onset  of  collapse.  The  patient  moves  the  bowels  about 
ten  to  twelve  times  in  twenty-four  hours.  The  evacuations  arc 
entirely  liquid,  like  water,  very  abundant  and  are  entirely  free 
of  bile  (the  diapers  are  wet  as  if  by  urine)  ;  they  are  turbid  bc- 


*Public  Health,  Aug.,  1903,  652,  quoted  from  Gould's  American   \'e-v 
Book  of  Medicine  and  Surgery,  1904,  p.  580. 
**Am.  Med.,  Sept.   13,  1902. 

***Jour.  Amer.  Med.  Assoc,  July  18,  1903,  pp.  I7S-J70- 
****Univ.  Pa.  Med.  Bui,  1902,  xv.,  407. 


t64  diseases  of  the  stomach  and  intestines 

cause  of  admixture  of  intestinal  epithelium  and  numerous  fungi ; 
the  reaction  in  the  beginning  is  acid,  later  on  alkaline,  with  a 
hardly  perceptible,  sometimes  ammoniacal  odor ;  the  belly,  because 
of  frequent  dejections,  is  soft  and  not  distended;  fever  is  usually 
absent,  but  temperature  rises  sometimes  in  the  commencement 
of  the  disease  up  to  102.5  to  104  degrees  F.  (39  to  40  degrees  C). 
Constant  vomiting  and  abundant  diarrhoea  are  accompanied  not 
only  by  severe  thirst  and  scanty  secretion  of  urine  (complete 
anuria  sets  in  sometimes,  as  in  epidemic  cholera),  but  also  by 
the  rapidly  occurring  appearances  of  collapse,  which  constitutes 
the  characteristic  symptom  of  infantile  cholera  as  against  a  sim- 
ple catarrh  of  the  stomach  and  bowels.  In  such  a  case  there 
are  noticed  first  of  all  frigidity  of  the  extremities,  small  and  fre- 
quent pulse,  great  weakness,  and,  later  on,  cyanosis  (of  the 
lips)  develops,  the  eyes  become  sunken,  the  pulse  almost  disap- 
pears, the  mucous  membrane  of  the  mouth  is  almost  cold  and 
covered  with  viscid  mucus ;  hoarse,  faint  voice ;  the  fontanelle 
depressed,  the  scalp-bones  slide  over  each  other  (the  margins  of 
the  frontal  and  occipital  bones  slide  under  the  margins  of  the 
parietal  bones).  Shortly  before  death  sclerema  appears,  that  is, 
hardening  of  the  skin  and  subcutaneous  tissue,  depending  upon 
the  absorption  into  the  blood  of  parenchymatous  fluids.  Sclerema, 
like  frigidity  of  the  limbs,  begins  at  the  feet  and  hands,  spread- 
ing over  the  back,  trunk  and  even  the  face.  In  the  latest  stage 
there  sets  in  somnolence,  contracture  of  the  neck  and  finally  death 
with  the  symptoms  of  so-called  hydrocephaloid. 

The  course  of  infantile  cholera  is  a  very  acute  one — death 
or  a  return  toward  recovery  occurs  in  a  few  days. 

Infantile  cholera  is  most  easily  confused  with  epidemic 
cholera,  inasmuch  as  the  symptoms  are  the  same  in  both  cases. 
The  diagnosis  is  based  upon  the  character  of  the  epidemic  ;  Asiatic 
cholera  does  not  spare  adults  any  more  than  children,  and  is  not 
so  much  dependent  upon  summer  heat  as  infantile  cholera, 
which  rapidly  abates  with  the  appearance  of  cool  days.  In  doubt- 
ful cases  one  should,  of  course,  resort  to  a  search  for  cholera 
bacilli  in  the  dejections.  For  this  examination  it  is  best  to  take 
mucous  lumps  which  swim  in  the  "rice"  dejections.  After  hav- 
ing prepared  from  them  a  dry  specimen  on  the  cover-glass  the 
latter  is  stained  with  methylene  blue  or  fuchsine   (slightly  heat- 


DISI'LVSES  OF  'lllK  STOM  \CII    AM)    I  NTICS'II  XF.S  1(35 

ing  for  two  or  three  niinutesj  and  examined  with  a  magificatii.n 
of  400  to  600.  Since  in  cholera  nostras,  and  sometimes  m 
cholera  infantum  (Lesage),  a  microbe  of  the  shape  of  a 
coma  ( Finkler-Prior's  coina),  resembling  very  much  Koch's 
cholera  coma,  is  found,  therefore,  it  is  necessary  for  a  positive 
diagnosis  to  make  cultures  according  to  methods  outlined  in  text- 
books on  bacteriology. 

[The  main  difference  between  Koch's  comma-bacillus  and 
that  of  Finkler-Prior  is  the  following:  If  some  pure  or  diluted 
acid  (sulphuric  or  hydrochloric)  be  added  (a  few  drops)  to  a 
twenty-four  hours'  old  bouillon-culture  of  cholera  bacilli,  then 
a  pinkish-red,  or  purple-red  color  will  be  obtained.  This  is  the 
so-called  nitroso-indol  reaction,  due  to  the  ability  of  the  cholera 
bacilli  to  form  indol,  and  to  convert  nitric  salts,  which  are  always 
contained  in  the  nutritive  media,  into  nitrous  ones.  The  Finkler- 
Prior  bacilli  do  not  possess  this  property,  so  that  their  cultures 
will  not  become  red  upon  the  addition  of  pure  hydrochloric  or 
sulphuric  acid  (i.  e.,  an  acid  which  does  not  contain  any  traces 
of  nitric  acid).* — Earle.] 

In  small,  as  well  as  in  older,  children  there  frequently  appear 
during  hot  summer  months  disorders  of  digestion  in  the  form 
of  very  fluid  and  foetid  dejections.  Such  foetid  diarrhoeas  are 
often  accompanied  by  fever,  and  sometimes  vomiting.  An  im- 
portant factor  in  their  aetiology  is  a  meat  diet. 

Symptoms  of  acute  catarrh  of  the  large  intestine — en- 
teritis follicularis — may  be  easily  explained  by  participation  of 
the  mucous  membrane  of  the  rectum  in  the  morbid  process.  The 
dejections  consist  especially  of  colorless  or  greenish  mucus, 
stained  sometimes  with  blood;  they  are  not  abundant,  but  very 
frequent.  The  patient  moves  the  bowls  about  ten  or  fifteen  times 
during  twenty-four  hours,  while  each  stool  is  accompanied  by 
painful  tenesmus  in  the  rectum  and  straining.  The  mucous  de- 
jections are  almost  odorless.  In  mild  cases  there  appears,  after 
a  few  mucous  evacuations,  normal  fluid  fseces  from  the  upper  por- 
tions of  the  intestines,  and  after  that  pure  mucus  again  appears. 
In  more  serious  cases  the  same  is  observed  only  after  taking 
physic,  but  in  the  most  severe  cases  f.necal  stools  cannot  be  pro- 

*Klemperer  and  Levy :  Grundviss  dcr  Kliiiislicn  Bactcriologie,  1895.  See 
also  Kahlden  :  Technik  dcr  Iiistologisclwii  Uiitrrsucliniig,  etc.,  i8g8,  p.  89. 


l66  DISEASES  OF  THE  STOMACH   AND  INTESTINES 

duced  even  by  means  of  castor-oil  (by  this  one  may  be  guidecT 
in  the  prognosis).  The  abdomen  usvially  becomes  sunken,  some- 
times thrre  may  be  noticed  painfulness  upon  pressure  in  the  re- 
gion of  the  descending  part  of  the  large  intestine.  The  further 
(hfference  between  follicular  enteritis  and  other  forms  of  catarrh 
consists  in  it  being  usually  accompanied  by  fever,  which,  how- 
ever, may  be  absent  in  mild  cases. 

Mild  forms  of  follicular  enterites  may  terminate  in  recovery 
in  two  or  three  days,  but  severe  ones  are  protracted  for  about 
two  or  three  weeks  and  more,  or  become  transformed  into  chronic 
intestinal  catarrh. 

Some  French  authors  ( Hammon,  Vigier,  Winter,  Delattre^ 
Lesage)  have  noticed  a  peculiar  form  of  diarrhoea,  which  is  de- 
scribed by  them  as  green  diarrhoea  (Hayem)  depending  upon  the 
chromogenous  green  bacillus  in  the  intestines.  Not  every  green 
diarrhoea  in  children  is  necessarily  of  bacillar  origin,  because  the 
green  color  of  the  dejections  may  depend  also  upon  the  admixture 
of  bile — this  is  the  bilious  green  diarrhoea  of  the  French  authors. 

Both  these  forms  of  green  diarrhoea  may  be  easily  distin- 
guished without  the  microscope ;  it  is  necessary  only  to  test  the 
faeces  with  nitric  acid ;  if  the  stain  depends  upon  bile,  then  the 
green  color  either  directly  becomes  transformed  into  a  violet  or 
pinkish  one,  or  it  becomes  at  first  of  deeper  color.  In  case,  how- 
ever, of  bacillar  diarrhcea,  the  faeces  become  colorless  under  the 
influence  of  nitric  acid. 

The  age  is  also  of  importance  in  the  diagnosis ;  biliary  diar- 
rhoea most  often  occurs  in  children  of  the  first  two  months- 
of  life,  in  whom  the  bacillar  diarrhoea  very  seldom  occurs.  On 
the  contrary,  between  two  and  twelve  months  the  green  diarrhoea 
depends  oftener  upon  the  chromogenous  bacillus.  After  two- 
years  the  latter  almost  never  occurs. 

Lesage  distinguishes  three  stages  of  the  green  bacillar 
diarrhoea  in  children  ;  the  mild,  medium  and  grave  ones.  The 
first  stage  is  afebrile,  the  number  of  the  dejections  is  not  more 
than  six,  and  recovery  takes  place  in  a  few  days.  In  the  medium 
form  the  number  of  dejections  is  from  six  to  ten,  the  child  has 
fever,  the  diarrhoea  is  frequently  protracted  to  a  chronic  form. 
In  the  severe  form,  or  the  cholera-like  green  diarrhcea,  the  num- 
ber of  the  dejections  equal  about  twenty,  collapse  comes  on  rap- 


DISEASES  OE  'tHE  STOAJ  \C11    AND   IXTESTIN'ES  167 

idly,  but  vomiting-,  in  contradistinction  to  cholera  infantum,  is 
usually  either  absent  altogether  or  is  insignificant.  Death  mav 
ensue  in  thirty-six  or  forty-eight  hours. 

ACUTE   DISEASES    OF   THE   STOMACH   AND    INTES- 
TINES IN  OLDER  CHILDREN. 

A  transient  catarrh  of  the  stomach  in  children  occurs  in  the 
acute  and  subacute  form. 

Acute  catarrh,  or  a  foul-stomach,  i^astritis  acuta,  s.  gas- 
tricisDiiis — not  infrequently  occurs  in  entirely  healthy  children 
after  coarse  or  faulty  diet  (abuse  of  candies,  especially  chocolate, 
fruits,  desserts,  etc.),  and  manifests  itself  from  the  first  by  vom- 
iting, usually  repeated,  and  violent  fever  (about  40  degrees  C. 
or  104  degrees  F. ) .  There  is  commonly  constipation  in  the  be- 
ginning, but  later  there  may  be  diarrhoea  associated  with  ab- 
dominal pains.  Complete  absence  of  appetite  is  noticed  from  the 
very  first,  with  bad  taste  and  disagreeable  odor  from  the  mouth, 
coated  tongue  and  considerable  thirst,  especially  for  cold  drinks. 

As  vomiting  frequently  occurs  during  the  rapid  elevation  of 
temperature,  the  same  as  in  other  diseases,  then  it  is  obvious  that 
the  diagnosis  of  such  gastritis  during  the  first  day  of  the  disease 
is  not  easy,  and  the  more  so  because  ever  a  coated  tongue  is  not 
characteristic  of  a  g'astritis  alone. 

For  the  proper  estimation  of  a  given  case  the  history  is 
extremely  important  (faulty  diet).  The  vomited  substance  con- 
sists usually  of  remnants  of  undigested  food  which  had  produced 
the  disease ;  distension  of  the  epigastrium  and  [^ain  upon  pressure 
thereon ;  relief  after  vomiting ;  finally,  rapid  recover}'  after  a  re- 
stricted diet  and  the  taking  of  some  physic.  The  absence  of  an 
epidemic  in  a  given  locality  makes  the  diagnosis  easier. 

The  second  form — gastritis  subacuta — begins  gradually 
with  loss  of  appetite,  headache,  general  weakness  and  malaise, 
with  insignificant  fever  and  jaundice,  but  frequently  without  any 
vomiting  and  diarrhcea  (although  both  may  be  present).  Fever 
varies  between  37.8  degrees  to  38.5  degrees  C.  (100  to  101.3 
degrees  F.)  being  sometimes  protracted  from  ten  to  fourteen 
days.  If  the  case  begins  with  vomiting,  then  it  is  easy  to  con- 
found the  disease  with  tubercular  meningitis,  which  also  com- 
mences with  vomiting,  headache,  constipation,  apathy  and  slight 
elevation  of  temperature. 


l68  DISEASES  OE  THE  STOMACH   AND   INTESTINES 

The  diagnosis  may  rest  upon  the  tongue  being  coated,  a  foul 
odor  from  the  mouth,  distension  and  sUght  painfuhiess  in  the 
epigastrium  during  pressure  upon  it,  as  well  as  the  ycUowishness 
of  the  conjunctk'CF.  Herpes  labialis.  which  is  rarely  observed 
during  tubercular  menmgitis,  but  frequently  met  with  in  "gastric 
fever"  is  also  of  diagnostic  value,  (^n  the  contrary,  against 
gastritis  and  in  favor  of  meningitis  will  be  an  irregular  and  at 
the  same  time  retarded  pulse  (the  irregularity  alone  without  re- 
tardation of  the  pulse  is  of  no  special  value),  slightly  sunken  ab- 
domen and  a  clean  tongue. 

Acute  catarrh  of  the  small  intestines  in  older  chil- 
dren differs  in  no  essential  manner  from  the  same  catarrh  in 
grown  persons.  This  malady  is  characterized  by  more  or  less 
frequent  (four  to  six  times  in  twenty-four  hours),  abundant, 
fluid  dejections,  accompanied  by  colicky  abdominal  pains. 

Chronic  catarrh  of  the  stomach  is  seldom  markedly 
developed  in  childhood,  being  more  peculiar  to  adults  and  charac- 
terized by  eructations,  heartburn,  vomiting  of  great  quantities  of 
mucus,  and  considerable  tenderness  of  the  epigastrium  (^n  pres- 
sure. Mild  degrees  of  stomach  catarrh  are  oftener  met  with  in 
which  the  patients  lose  their  appetite,  grow  thin,  become  languid 
and.  in  general,  represent  the  picture  of  ansemia  which  was  spoken 
of  in  the  section  on  Appetite,  where  was  also  indicated  the  points 
for  the  differential  diagnosis. 

Chronic  gastritis  in  children  is  comparatively  seldom  asso- 
ciated with  dilatation  of  the  stomach.  The  chief  symptoms  of 
the  latter  consist  in  abundant  vomiting  by  which  there  is  ejected 
food  taken  more  than  twenty-four  hours  before,  and  in  the  con- 
siderable spreading  of  the  tympanitic  tone  of  the  stomach  (to  the 
level  of  the  umbilicus,  and  also  below).  Taking  an  effervescent 
mixture  sometimes  renders  visible  the  boundaries  of  the  stomach. 

In  doubtful  cases  examination  by  means  of  the  stomach- 
tube  should  be,  as  in  adults,  resorted  to. 

Chronic  catarrh  of  the  rowels  is  one  of  the  commonest 
diseases  of  childhood.  This  condition  develops  from  any  acute 
intestinal  catarrh,  being  especially  often  the  consequence  of  dysen- 
tery or  summer  complaint,  but  diarrhoea  sometimes  seems 
to  appear  from  the  very  first  in  the  chronic  form,  that  is,  one 
cannot  find   in   the  historv  of  the  case  a  violent  diarrhoea,  the 


DISEASES  OF  THE  STOMACH   AXlJ   INTESTINES  16<i 

parents  claiming-  the  trouble  had  been  all  the  time  in  the  same 
■condition  as  when  they  decided  to  consult  the  physician. 

The  symptoms  of  chronic  intestinal  catarrh  vary  depending 
upon  the  intensity  of  the  disease  and  its  localization.  As  acute 
•catarrh  of  the  intestines,  especially  of  the  small  ones,  when  be- 
coming chronic,  does  not  remain  at  the  place  of  its  primary  ap- 
pearance, but  spreads  commonly  over  the  whole  intestinal  tract, 
therefore,  it  is  impossible  to  mark  definitely  the  limits  between 
a  catarrh  of  the  small  intestines  from  that  of  the  large. 

The  most  common  symptom  of  chronic  catarrh  of  the  large 
intestines  (but  not  of  their  lower  portion)  is  constipation.  The 
patient  voluntarily  moves  the  bowels  once  in  two  or  three  days, 
the  fseces  being  firm  ;  or  it  is  necessary  to  resort  too  often  to 
enemata.  The  dejections  are  mingled  with  great  quantities  of 
mucus,  by  which  this  catarrhal  constipation  differs  from  the  so- 
called  habitual  constipation. 

In  the  second  form  the  chronic  intestinal  catarrh  is  charac- 
terized by  the  constant  alternation  of  constipation  ajid  diarrlnra. 
This  alternation  sometimes  occurs  with  remarkable  regularity ; 
two  or  three  days'  constipation  being  followed  by  one  or  two 
days'  diarrhoea,  consisting  of  stinking,  fluid  dejections  abund- 
antly mingled  with  mucus.  In  other  cases  there  is  no  regularity ; 
the  child  normally  moves  his  bowels  for  weeks  at  a  time,  or  there 
may  be  noticed  an  inclination  toward  constipation,  but  under 
the  influence  of  some  dietetic  errors  diarrhoea  appears. 

Finally,  in  the  third  series  of  cases,  chronic  intestinal  catarrh 
manifests  itself  by  daily  diarrhoea.  The  patient  moves  the  bowels 
■once,  twice,  or  three  times  a  day,  the  stools  being  very  foetid, 
thin,  usually  of  grayish,  loamy  and  dark-brown  color.  The  in- 
volvement of  the  small  intestines  is  in  such  cases  most  probable. 
Foetid  diarrhoea  seems  to  assume  in  some  cases  a  periodical 
course  ;  two  or  three  stools  in  succession  occur  during  the  night 
or  in  the  early  morning,  and  then  the  patient  is  constipated  during 
the  whole  day :  or  thin  stools  immediately  follow  the  meals.  In 
both  these  cases  one  may  positively  suspect  afl:'ection  of  the  large 
intestines. 

Furthermore,  of  characteristic  importance,  in  affection  of 
the  large  bowels  may  be  mentioned  mucus  mingled  with  the  de- 
jections  and   some   tenderness  over   the  area  of   the   colon   and 


170  DISEASES  OF  THE  STOMACH   AND   INTESTINES 

caecum.  In  the  case  of  an  isolated  affection  of  the  bowels,  the- 
functions  of  the  stomach  and  small  intestines  being  normal,  there- 
is  to  be  noticed  no  relationship  between  the  duration  of  the 
diarrhoea  and  the  good  general  aspect  of  the  patient ;  despite  the 
protracted  diarrhoea  (continuing  months),  the  subcutaneous  fatty 
tissue  does  not  disappear,  the  pallor  of  the  integument  and  mu- 
cous membrane  being  insignificant,  the  tongue  clean,  the  appe- 
tite excellent. 

If  the  catarrh  be  mostly  limited  to  the  upper  portion  of  the- 
small  intestine,  then  the  stomach  is  also  involved ;  the  patient 
loses  his  apjjetite,  grows  thin  and  pale,  the  conjunctivae  are- 
icteric,  pressure  on  the  epigastrium  is  somewhat  painful,  but 
diarrhoea  may  be  entirely  absent,  and  the  involvement  of  the  in- 
testines is  evidenced,  besides  the  yellowishness  of  the  conjunc- 
tivae, bv  rumbling  in  the  abdomen,  meteorism  and  sometimes  by 
colicky  abdominal  pains. 

A  peculiar  picture  is  exhibited  by  chronic  diarrhoea  in  the- 
case  of  a  more  or  less  considerable  afifection  of  the  rectum,  which 
happens  so  often  in  small  children,  under  three  years  of  age,, 
during  chronic  follicular  enteritis  as  a  sequel  of  dysentery.  Al- 
though foetid  dejections  occur  in  such  cases,  as  in  any  other 
chronic  intestinal  catarrh,  yet  sometimes  there  are  also  to  be  seen- 
dejections  entirely  peculiar  to  the  afifection  of  the  rectum  ;  they 
are  scanty,  consisting  especially  of  purulent  mucus,  intermingled 
sometimes  with  blood,  being  accompanied  by  distinct  tenesmus,, 
and  eventually  by  pains.  The  number  of  stools  is  seldom  less 
than  six,  usually,  however,  more  than  ten  (during  twenty-four 
hours)  ;  therefore  the  distension  of  the  abdomen  during  enteritis 
follicularis  chronica,  even  when  complicated  with  catarrh 
of  the  large  bowels,  never  reaches  such  a  degree  as  in  the  usuat 
catarrh.  Even  if  the  abdomen  be  somewhat  distended,  it  is  at 
any  event  soft  and  doughy-like.  Wasting  reaches  the  highest 
degree,  the  subcutaneous  fat  disappears,  oedemata  of  the  upper 
and  lower  extremities  being  common,  and  in  some  cases  general' 
dropsy  develops,  with  accumulation  of  fluid  in  the  serous  cavi.- 
ties.  In  all  CTses  the  children  sufifer  from  insomnia  and  are  very 
thirsty. 

In  the  presence  of  any  ciironic  diarrhoea  the  question  may 
arise  whether  the  diarrhoea  does  not  depend  upon   tuberculosis- 


DISEASES  OF  THE  STOMACH  AND   INTESTINES 


171 


of  the  intestines  and  whether  there  is  in  the  child  any  caseous 
(tubercular)  degeneration  of  the  mesenteric  glands.  Since  we  do 
not  know  the  symptoms  which  would  point  especially  to  such  in- 
volvement (tubercular  degenerated  mesenteric  glands  may 
coalesce  with  each  other,  thus  sometimes  forming  quite  large 
tuberculous  tumors  in  the  area  of  the  umbilicus  or  in  the  lateral 
regions ;  but  such  a  tumor,  during  lifetime,  is  very  difficult  to  be 
felt,  the  examination  being  usually  prevented  by  the  tension  of 
the  abdominal  walls  because  of  meteorism),  therefore,  we  may 
suspect  the  existence  of  tuberculosis  of  the  intestines,  or  of 
the  glands  only,  in  a  case  where  the  chronic  diarrhoea  arises  in 
a  child  suffering  from  tuberculosis  of  some  other  organs.  In 
addition  to  this  we  give  here  a  diagnostic  table,  taken  from  Wider- 
hofer :" 


Chronic 
catarrh. 


intestinal 


Tuberculosis  of  the 
intestines. 


Caseous  degenera- 
tion of  the  mesenter- 
ic glands. 


Most  often  occurs 
in  children  after 
weaning,  then  rarer 
and  rarer  up  to  four 
years. 


Generally  appears 
not  earlier  than  th.e 
third  year,  oftener  In 
children  of  tubercular 
parents. 


Almost  never  be- 
fore the  third  year; 
most  common  be- 
tween the  age  of  five 
and  ten  years,  usually 
in  children  of  tuber- 
cular parents. 


The  stools  are  not 
abundant,  but  the 
diarrhoea  is  persist- 
ent, even  if  only  two 
or  three  times  a  day.- 


The  diarrhoea  stops 
for  a  few  days  or 
weeks,  then  appears 
again ;  the  diarrhoea 
becomes  constant 

only  in  the  case  of 
extensive  affection  of 
the  bowels. 


Diarrhoea    intermit- 
tent. 


Stools  consist  of 
mucus,  pus  and  blood, 
alternating  with  ca- 
tarrhal and  pap-like 
dejections,  which 
contain  indigestible 
remains  of  food  (only 
when  they  are  very 
frequent). 


The  stools  consist 
exclusively  of  ffeces, 
some  food  is  elimi- 
nated entirely  undi- 
gested, especially  sub- 
stances rich  with  fat, 
as  brain,  yolk  of  an 
egg,  solid  fat. 


The  chief  constitu 
ent   is   water;    in  the 
stools  there  is  also  a 
great    deal     of     fat, 
swimming  on  the  sur 
face  of  fluid  and  eas 
ily  recognized  by  th« 
eye. 


*Jahrh.  fiir  Kinderh.    Vl  B.,  pages  16,  17.    Die  Seniiotik  des  Unterleibs. 


\']2 


DISEASES  OF  THE  STOMACH   AND  INTESTINES 


Chrome      intestinal 
catarrh. 


Tuberculosis  of  the 
intestines. 


Caseous  degenera- 
tion of  the  mesenter- 
ic glands. 


Mucous  dejections 
are  eliminated  with 
teniesmus,  the  catar- 
rhal with  colic-like 
pains. 


The  pains  are  colic- 
like, never  severe,  be- 
ing usually  accom- 
panied by  chilliness. 


Pams  are  unusual 
during  movement  of 
the  bowels ;  they  set 
in  suddenly  and  soon 
pass  away;  returning 
very  often  after  eat- 
ing. 


The  abdomen  is 
usually  distended  in 
the  region  of  the 
transverse  colon  and 
the  lower  portion  of 
the  descending  colon, 
and  especially  the  sig- 
moid flexure  appears 
swollen  and  painful 
upon  strong  pressure. 


A  noticeable  expan- 
sion is  nowhere  visi- 
ble ;  frequently  the 
entire  abdomen  is  soft 
and  sensitive  upon 
pressure ;  the  region 
of  the  caecum  is  some- 
times tense  and  pain- 
ful during  deep  in- 
spiration. 


The  abdomen  is 
distended  and  tense, 
being  in  some  places 
(in  chronic  peritoni- 
tis) very  sensitive;  in 
such  a  case  painful 
nodes  may  be  palpat- 
ed in  the  region  of 
the  umbilicus,  being 
firmly  attached  to  the 
abdominal,  wall  and 
immovable. 


The  fever  is  moder- 
ate, with  equal  red- 
ness of  the  cheeks 
during  the  fever.  The 
skin  is  either  dry  or 
livid,  pale. 


The  fever  is  mod- 
erate, the  exacerba- 
tions are  marked  by 
chills;  a  limited  red- 
ness of  the  cheeks ; 
the  skin  dry,  covered 
on  the  hands  and 
thighs  by  brownish 
scales  (pityriasis  ta- 
bescentium)  a  n  d 
abundant  hairs. 


The  fever  is  very 
moderate,  being 
sometimes  entirely 
absent ;  the  skin  is 
very  dry  and  pale.  On 
the  skin  of  the  abdo- 
men lymphatic  glands 
in  the  form  of  small 
nodules  may  be  pal- 
pated. 


The  lips  are  dry, 
•exulcerated,  and  the 
patient  is  continually 
tearing  off  the  scales. 


The 


Normal.  The  pa- 
tient is  persistent  in 
asking  for  dry, 
starchv  food. 


The     other     organs 
are  healthy. 


Tuberculosis  of  the 
lungs  may  often  be 
proven ;  there  is  us- 
ually hyperplasia  or 
caseous  degeneration 
of  the  peritoneal 
glands;  considerable 
swelling  of  the  ingui- 
nal and  cervical 
glands  never  fails. 


Swel'ing  and  hard- 
ness of  the  inguinal 
and  bronchial  glands; 
;crofu!osis  (tubercu- 
losis of  the  other  or- 
gans). 


DISEASlvS  OF  THE  STOMACH   AM)   INTESTl  N ICS 


U3 


Chronic      intestinal 
•:atarrJi. 


Tuberculosis  of  the  Caseous     dcgenera- 

intcstines.  tion  of  the  mesenter- 

ic glands. 


Was  ting  starts 
much  later  than  the 
appearance  of  the 
diarrhoea. 


Drugs  and  rest  are 
always  of  some  use, 
relapses  usually  are 
produced  by  errors  in 
diet.  The  greatest 
success  is  to  be  ex- 
pected from  complete 
change  of  the  diet 
and  climate. 

The  duration  is 
from  four  up  to  eight 
weeks,  then  complete 
recovery  occurs  with 
the  end  of  fever. 
Sometimes  cases  are 
protracted  for  one 
year  and  longer. 


Wasting  sets  in 
quickly  and  is  grad- 
ually progressive. 


Drugs  and  rest  in 
bed  are  either  of  no 
value,  or  the  diar- 
rhoea stops  only  for  a 
while,  reappearing 
without  any  noticea- 
ble cause. 


Duration  is  about 
two  to  six  months ;  in 
the  case  of  some  im- 
provement one  can 
not  expect  it  will  be 
permanent. 


Wasting  sets  in 
slowly ;  during  the  in- 
terruptions the  pa- 
tient somewhat  im- 
proves. 

Drugs  and  rest  act 
as  in  catarrh,  but  re- 
lapses are  frequent. 


Uncertain  durabil- 
ity. Recovery  is  pos- 
sible if  neither  peri- 
tonitis or  other  seque- 
l?e  of  tuberculosis  of 
the  glands  develops. 


Ill  children  not  very  infrequently  there  is  observed  a  pecn- 
Har  form  of  chronic  diarrhoea,  which  is  the  manifestation  of 
masked  malaria,  being  distinguished  from  many  other  forms  of 
chronic  diarrhoea  by  its  periodicity. 

Such  periodical  diarrhoeas  occur  in  children  between  five  and 
ten  years  of  age  (according  to  Bohn  oftener  in  nurslings).  The 
child  has  three  to  five  thin,  ofifensive,  fa?cal  stools,  usually  within 
a  few  hours,  while  for  the  rest  of  the  twenty-four  hours  the 
stools  are  normal  or  there  is  no  movement  of  the  bowels.  Such 
an  alternation  of  fluid  dejections  and  normal  ones  is  characteris- 
tic enough  for  cases  of  malarial  diarrhoea.  This  disease  always 
appears  in  paroxysms,  every  day,  and  approximately  at  the  same 
time  of  day,  mostly  during  the  night  or  in  the  morning.  Eleva- 
tion of  temperature  seldom  occurs  during  the  period  of  diarrhoea, 
but  the  spleen  often  appears  so  swollen  that  it  may  be  palpated. 
As  the  stomach  digestion  is  not  disturbed  at  all  the  tongue  during 
malarial  diarrhoea,  as  well  as  in  some  forms  of  catarrh  of  the 
large  bowels,  remains  clean,  the  appetite  good,  the  general  nutri- 
tion fair. 


174  DISEASES  OF  THE  STOMACH  AND   INTESTINES 

The  important  peculiarity  of  malarial  diarrhoea  consists  in 
its  not  yielding  either  to  dietetic  treatment,  to  laxative  remedies, 
or  to  opiates  and  astrmgents,  but  it  quickly  passes  away  upon  the 
use  of  quinine.  One  or  two  doses  of  quinine,  given  a  few  hours 
before  the  appearance  of  the  thin  stools,  is  often  sufficient  to  stop 
the  diarrhoea  at  once,  even  if  it  had  failed  to  yield  to  any  other 
treatment  for  several  months. 

In  recent  cases  malarial  diarrhoea  usually  manifests  itself  in 
the  form  of  mucous  or  bloody  discharges  accompanied  by  tenes- 
mus and  elevated  temperature.  It  is  remarkable  that  the  fever 
sometimes  lasts  only  a  day,  but  it  is  very  high,  for  instance,  about 
40  degrees  C.  (104  degrees  F.)  so  that  the  bloody  diarrhoea  is 
at  first  feared  by  the  physician  because  of  such  a  high  temper- 
ature, but  the  further  course  of  the  disease  proves  its  nature. 

The  periodicity,  in  these  acute  forms  of  malarial  diarrhoea, 
is  not  expressed  as  distinctly  as  in  the  chronic  forms,  because 
while  mucous  dejections  may  appear  during  any  of  the  twenty- 
four  hours,  in  some  hours  only  does  the  frequency  of  the  stools 
increase  considerably.  However,  in  mild  cases  there  may  be 
noticed  a  strong  periodicity  even  in  acute  forms,  while  during 
apyrexia  the  stools  are  normal. 

According  to  Bohn*  bloody  malarial  diarrhoea  difYers  from 
a  common  diarrhoea  by  the  absence  of  tenesmus,  straining  and 
abdominal  pains,  but  this  is  far  from  being  true  in  all  cases. 

In  acute  cases  malarial  diarrhoea  may  be  mistaken  for  a 
common  mucous  diarrhoea  or  dysentery,  and  chronic  diarrhoea 
for  chronic  catarrh  of  the  large  intestines,  but  the  diagnosis  is 
indeed  not  difficult.  It  is  based  essentially  upon  the  typical 
periodicity  of  the  diarrhoea  (only  one  must  not  expect  its  re- 
currence at  precisely  the  same  hour,  the  diiTerence  of  two  or  three 
hours  being  immaterial). 

The  diagnosis  may  be  aided  in  acute  cases  by  the  initial  ele- 
vation of  temperature  and  the  tumor  of  the  spleen  (although 
both  are  not  very  essential)  ;  in  chronic  cases,  by  the  cheerful 
aspect  of  the  patient,  his  clean  tongue,  fair  appetite,  tumor  of  the 
spleen  and  the  history  (the  patient  either  was  sick  from  malaria, 
or,  at  least,  had  lived  in  a  malarial  place,  in  a  damp     dwelling. 


^Jahrb.  f.  Kinderkr.,  1873,  IV.  S.,  115. 


DISEASES  OF  THE  STOMACH    AND   INTESTINES  175 

-etc.),  as  well  as  by  the  failure  of  opium  treatment  and  other  com- 
mon remedies. 

In  spite  of  the  seeming  ease  of  diagnosis  malarial  diarrhoea 
is  far  from  being  always  readily  recognized.  It  often  happens 
that  a  patient  suffering  from  chronic  diarrhoea  goes  from  one 
physician  to  another,  tries  many  drugs  recommended  for  chronic 
intestinal  catarrh,  and  finally  recovers  quickly  after  taking  a  few 
grains  of  quinine.  Such  misunderstandings  arise  from  the  lack 
of  acquaintance  of  physicians  with  malarial  diarrhoea,  which  un- 
justly is  held  as  of  rare  occurrence.  Physicians  forget  about  its 
existence ;  therefore,  inquiring  about  the  number  of  stools,  they 
never  ask  zirheii  the  patient  moves  the  bowels,  in  what  particular 
hours ;  and  this  is  the  real  point  ;*  obviously,  to  recogui::e  easily 
malarial  diarrJma  the  nature  of  the  disease  must  he  kept  in  mind. 

One  must,  however,  remember  that  periodicity  alone  is  in- 
-sufificient  for  the  correct  diagnosis  of  malarial  diarrhoea,  because, 
undoubtedly,  some  cases  of  catarrh  of  the  large  intestines  (as 
mentioned  above)  are  also  expressed  by  a  periodicity  in  the 
diarrhoea,  while  the  stools  are  foetid,  fluid,  appearing  usually  in 
the  early  morning,  two  or  three  in  number  during  a  short  time, 
but  in  the  day-time  the  patient  does  not  move  the  bowels  at  all, 
•or  moves  them  only  soon  after  eating.  In  Prof.  Tchernofif's  opin- 
•ion**  such  a  diarrhoea  depends  upon  an  affection  of  the  caecum, 
which  is  denoted,  in  his  opinion,  by  the  intense  tympanitic  note 
on  percussion  of  the  cscal  region,  rumbling  at  this  point  and  pain 
or  a  disagreeable  sensation  upon  pressure.  If  the  abdominal 
muscles  are  not  tense,  then  one  may  distinctly  feel  the  thickened, 
painful  margin  of  the  caecum,  as  if  slipping  out  from  under  the 
fingers,  when  the  abdomen  is  palpated  on  the  first  third  of  a 
line  connecting  the  anterior  upper  iliac  spine  with  the  umbilicus, 
or  somewhat  higher,  and  sometimes  lower.  There  appears  simul- 
taneously some  tenderness  in  the  sigmoid,  and  in  general  an 
■exaggerated  sensitiveness  over  the  whole  tract  of  the  large  bowel 
may  be  noted.  According  to  Tchernoff,  such  diarrhoeas  pointing 
to  catarrh  of  the  caecum  (and  later  of  the  large  bowel  in  gen- 
>eral)  are  most  often  the  result  of  an  acute    neglected     entero- 


*This  is  also  the  fault  of  the  text-books  on  Children's  Diseases,  in  the 
jnajority  of  which  malarial  diarrhoea  is  entirely  ignored. 

**Perityphlitis  and  Paratyphlitis  in  children,  Kiev,  1892,  p.  31. 


176  DISEASES  OF  THE  STOMACH   AND  INTESTINES 

colitis  (that  is,  of  an  acute  or  bloody  diarrhoea)  ;  and  according- 
to  Edlefsen*  periodical  diarrhcEa  is  the  most  certain  si^^n  of 
catarrh  of  the  large  bowels  due  to  coprostasis.  Whatever  it  may 
be,  it  is  true  that  periodical  diarrhoea  sometimes  occurs  during 
catarrh  of  the  large  bowel,  differing  from  malarial  diarrhcea  in 
the  tenderness  of  the  abdomen  on  pressure  over  the  region  of 
the  large  bowels,  and  by  not  yielding  to  quinine,  but  rather  to- 
castor-oil,  milk  diet  and  large  enemata  of  one  per  cent,  solution 
of  tannin.  Meat  and  fat  must  be  positively  forbidden  during  such, 
a  diarrhoea. 

We  have  yet  to  say  a  word  about  a  peculiar  chronic  lesion 
of  the  intestines  known  as  enteritis  mcmbranacea,  s.  colica  mu- 
cosa. The  disease  is  characterized  by  attacks  of  abdominal  pairt 
accompanied  by  the  voiding  of  mucus  per  anum,  either  in  the 
form  of  membranes  resembling  tape-worm,  or  in  that  of  casts 
(the  impress  of  the  intestinal  segment),  or  simply  in  the  form  of 
nests  of  mucus. 

Together  with  the  mucus  there  is  also  generally  a  discharge 
of  faeces  in  the  form  of  separate  dry  lumps  ;  but  this  is  significant^ 
because  nuicus  may  also  l>e  voided  without  fscal  matter  or  ac- 
companied by  pap-like  stools.  The  discharge  of  mucus  lasts  one 
or  two  days,  or  several  days  in  succession,  when  it  stops  for  an 
indefinite  time ;  the  intervals  between  the  attacks  lasting  in  some 
cases  several  weeks,  while  the  attacks  in  graver  cases  are  re- 
peated every  week.  To  the  characteristic  signs  of  the  disease 
also  belongs  constipation  in  the  period  of  the  intervals.  In  contra- 
distinction from  proctitis,  in  which  much  mucus  is  also  voided^ 
there  is  neither  tenesmus  nor  straining.  The  disease  always  has 
a  chronic  course,  lasting  months  and  even  years,  although  in 
some  cases  it  is  limited  to  one  or  two  attacks.  In  many 
cases  the  patients  are  very  sensitive  to  errors  of  diet ;  a  small 
increase  in  the  amount  of  food,  or  a  change  in  its  quality  (un- 
common food),  are  sufficient  for  the  appearance  of  the  attack. 
Some  patients  do  not  tolerate  meat,  others,  milk,  and  still  others- 
something  else,  so  that  each  separate  case  demands  individual- 
izing when  the  diet  is  administered,  this  being  determined  by  ex- 
perience. 

The  majority  of  contemporary  authors  regard  this  affection 

*Lchrb.  dcr  Diagnostik  dcr  inncrcn  Krankheiteii,  1890,  p.   109. 


DISEASES  OF  THE  STOMACH   AND   KVTESTINES  I77 

not  as  a  catarrh  of  the  large  bowels,  but  as  a  neurosis.  The 
latter  may  manifest  itself  by  increased  activity  of  the  mu- 
cous glands,  and  is  favored,  first,  by  the  periodical  course,  and 
second,  by  its  appearance  mostly  in  nervous,  hysterical  women. 
According  to  our  observations  "nervousness"  in  childhood  does 
not  play  the  leading  role,  although  it  cannot  be  denied  that  a  neu- 
ropathic heredity  and  a  tender  constitution  (white,  soft  hair;  thin, 
transparent  skin;  thin  bones;  scanty  fatty  tissue)  are  often  noted 
in  such  children.  On  the  other  hantl,  it  cannot  be  doubted  that 
membranous  enteritis  occurs  in  those  children  who  either  have 
suffered  since  early  childhood  from  diarrhsea  alternating  with 
constipation,  or  who  shortly  before  had  been  sick  with  dysen- 
tery ;  in  a  word,  the  influence  of  the  intestinal  catarrh  is  very 
probable  in  such  cases.  On  this  account  Nothnagel  says  that  there 
are  probably  two  forms  of  membranous  enteritis ;  one  purely 
nervous  and  the  other  catarrhal.  In  the  former  the  discharge  of 
mucus  is  accompanied  by  attacks  of  violent  pairi  (colica  mucosa), 
in  the  latter  there  is  no  pain,  or  if  present,  is  not  severe. 

[Membraneous  enteritis  is  of  frequent  occurrence  in  child- 
hood, being  often  accompanied  by  inconsiderable  elevation  of  tem- 
perature (Comby,  Hutinel).  Three  symptoms  are  essential  to  this 
disease : 

( 1 )  Elimination  of  mucous  masses. 

(2)  Irregular  activity  of  the  intestines. 

(3)  Abdominal  pains. 

Regarding  the  first  point  it  should  be  noted  that  the  mucous 
masses  may  be  discharged  in  (a)  an  amorphous,  and  (b)  incin- 
branoform  state.  The  former  resembles  the  white  of  a  more  or 
less  coagulated  egg,  being  sometimes  intermingled  with  blood ; 
the  latter  appears  under  the  form  of  real  pseudo-membranes  of 
dififerent  dimensions,  resembling  either  cylindrical  tubules  or  some 
variety  of  intestinal  worms  (oxyuris  vermicularis  and  tape- 
worms). The  histological  peculiarities  are  those  of  mucus  mixed 
in  different  proportions  with  epithelial  cells,  epithelial  nuclei,  and 
leucocytes.  As  to  the  second  point — the  irregularity  of  the  bow- 
els— it  may  be  said  that  constipation  is  very  characteristic  of  this 
disease,  being  obstinate  and  prolonged,  followed  by  persistent 
diarrhcea,  and  in  older  persons,  with  hsemorrhage  (due  to  ulcera- 
tions of  the  mucous  membrane    or   to     its     hyperemia).       The 


178  DISEASES  OF  THE  STOMACH   AND  INTESTINES 

diarrhaa  in  its  turn  gives  place  to  a  return  of  constipation,  so 
that  periodical  onset  of  persistent  constipation  and  diarrhoea  is  a 
very  notable  feature  of  membranous  colitis. 

The  pain,  which  is  the  third  cardinal  symptom,  is  of  different 
character  and  location,  being-  usually  confined  to  the  right  iliac 
fossa, and  thence  either  around  the  umbilicus, or  spreading  all  over 
the  abdomen.    The  pain  sonietnnes  occurs  in  the  form  of  crises. 

Of  other  symptoms,  Maurice  de  Langehagen.  who  wrote  a 
very  exhaustive  article  on  this  subject,*  points  out  the  following: 
( I )  Flaccidity  or  flabbiness  of  the  abdominal  walls,  their  de- 
pressibility  which  allows  a  thorough  palpating  of  the  alxlomen 
down  to  the  vertebral  column;  one  may  thus  (2)  palpate  the  in- 
testines and  ( 3 )  ascertain  the  loss  of  their  elasticity  and  their 
tonus  (only  of  the  large  intestines).  Sometimes,  however,  it  is 
possible  (4)  to  note  a  tension,  or  hardness  of  the  intestines,  so  that 
some  intestinal  segments  may  seem  to  be  in  the  condition  of  com- 
parative stenosis,  others,  in  that  of  dilation.  This  observation  is 
explained  bv  the  s]:)asmodic  condition  into  which  the  intestinal 
segments  are  sometimes  excited.  (5)  h\u"ther,  it  is  very  often 
possible  to  detect  in  the  region  of  the  c?ecum  gurgling  and  tur- 
bulence ("gargouilement  et  clajjotage"  of  the  h'rench  authors) 
along  the  transverse  colon. 

i^)esides  these  symptoms  some  disorders  on  the  part  of  the 
liver  (hypen-emia,  enlargement,  or  contraction)  ;  of  the  stomach 
(distension  and  different  gastric  disorders — anorexia,  coated- 
tongue,  nausea,  vomiting,  etc.)  are  observed. 

In  the  differential  diagnosiss  it  should  be  remembered  that 
tubercular  enteritis  bears  a  close  resemblance,  from  which  mem- 
branous enteritis  differs  by  the  occasional  persistent  constipations, 
by  the  absence  of  tubercular  evidences  in  other  organs,  by  the 
location  and  character  of  the  pain  (crises),  and  above  all  by  the 
periodicity  and  the  extremely  protracted  course.  This  long  course 
produces  a  marked  cachexia,  which  may  likewise  result  from  tu- 
berculosis of  the  intestines  and  chronic  intestinal  catarrh. 

Mucous  enteritis  is  considered  by  most  authors  as  a  mani- 
festation of  some  diathetic  nervous  disorders.  Langehagen  re- 
gards it  as  connected  with  a  neuro-arthritic  diathesis. — Earle.] 


*L'enterocolite  muco-membraneuse  ;  symptomes,  etiologie  et  traitement. 
La  Scmainc  Medicate,  1898,  No.  i,  pp.  1-7. 


SEMEIOLOGY  OF  BLOODY  INTESTINAL 
DEJECTIONS. 

The  presence  of  blood  in  the  dejections  may  usnally  be 
easily  recognized  from  mere  inspection  of  the  stools,  the  color 
and  aspect  of  which  vary  depending  not  only  npon  the  amount  of 
mingled  blood,  but  also  upon  the  location  of  the  hccmorrhage 
(that  is,  near  to  or  far  from  the  stomach),  and  how  long  the 
blood  remained  in  the  bowels.  Generally  speaking  the  nearer  the 
hjemorrhage  to  the  stomach  the  longer  the  blood  remains  in  the 
bowels,  and  thus  the  more  it  undergoes  changes  from  the  action 
of  the  alimentary  juices,  being  therefore  strongly  altered  in  color 
when  eliminated  (becomes  dark).  The  blood  corpuscles  appear 
under  the  microscope  disfigured  or  completely  destroyed.  In  such 
cases  the  blood  has  time  to  be  mingled  with  the  faeces, 
which  become  of  equal  dark-brown  or  even  darker  color.  But  a 
dark  color  of  the  fseces  is  also  observed  after  the  use  of  certain 
substances,  for  instance,  iron,  blackberries,  coal,  etc. 

To  recognize  the  admixture  of  blood  in  doubtful  cases  a  par- 
ticle of  faeces  has  to  be  dissolved  in  water ;  the  latter  then  im- 
mediately becomes  stained  a  red  color  from  the  presence  of  blood. 
In  the  case  of  further  doubt.  Heller's  test  may  be  resorted  to  (see 
page  ISO). 

Blood  without  admixture  of  f.neces  usually  comes  from  the 
colon.  If  the  evacuations  be  often  and  the  haemorrhages,  even 
when  they  occur  in  the  upper  portions  of  the  bowels,  copious  and 
repeated,  then,  in  these  cases,  the  stools  may  consist  of  blood 
alone,  which  is  eliminated  either  fluid,  tar-like,  or  coagulated, 
but  at  any  rate  dark  and  much  altered.  Pure,  crimson-colored 
blood,  not  intermingled  with  faeces,  but  only  streaking  the  latter, 
positively  comes  from  the  rectum. 

The  causes  of  haemorrhage  change  with  the  age  of  the  child, 
therefore  we  do  not  observe  in  the  later  stages  of  chiklhood  some 
kinds  of  haemorrhage  which  are  met  with  in  nurslings,  so  that 
all  cases  referred  to  here  mav  be  divided  into  two  groui)s. 


l80  DISEASES  OF  THE  STOMACH   AND   INTESTINES 

To  the  first  belong  intestinal  hgemorrhages  observed  exclu- 
sively in  young  children  during  the  first  months  of  life ;  to  the 
second  those  in  older  children. 

To  the  first  group  are  referred  intestinal  haemorrhages  in 
nielana  neonatorum  and  in  temporary  haemophilia,  which  were 
spoken  of  in  the  section  on  bloody  vomiting  (page  148). 

According  to  Bohn,  bloody  dejections  in  children  under  one 
year  of  age  often  appear  because  of  malaria. 

Bloody  dejections  in  older  children  also  occur  from  gastric 
or  intestinal  haemorrhages.    The  causes  of  the  latter  are : 

(i)  Constitutional  diseases,  the  so-called  diseases  of  the 
blood. 

(2)  Diseases  of  remote  organs  in  which  the  reflux  of  the 
blood  from  the  intestinal  veins  is  hindered. 

(3)  Diseases  of  the  intestinal  walls  themselves. 

To  the  diseases  of  the  first  category  belong  variola  hieni- 
orrhagica,  morbus  maculosus  Werlhofii  and  scurvy.  In  all  these 
cases  the  haemorrhage  usually  occurs  in  the  upper  portions  of  the 
bowels,  so  that  the  blood  is  seen  to  be  either  intimately  inter- 
mingled with  the  faeces,  or  without  the  latter  if  the  haemorrhages 
be  repeated  and  frequent,  but  at  any  event  it  is  considerably 
changed. 

The  diagnosis  is  not  difficult  in  the  majority  of  cases,  being 
made  on  the  ground  of  alterations  exhibited  by  the  skin  and  the 
mucous  membranes  peculiar  of  any  given  disease,  as,  for  instance, 
affection  of  the  gums  in  scurvy,  purjiura  in  Werlhof's  disease, 
etc.  It  is  most  difficult  to  recognize  hjemorrhagic  small-pox, 
especially  in  the  beginning  of  a  small-pox  epidemic,  because 
haemorrhagic  variola  takes  place  very  quickly,  frequently  causing 
the  death  of  the  patient  before  the  papulous  small-pox  eruption 
appears.  Petechiae  in  the  skin  and  hremorrhages  into  the  internal 
organs  appear  as  early  as  on  the  first  day  of  the  prodromal  pe- 
riod, accompanied  by  very  high  fever  with  delirium  and  convul- 
sions. 

Among  general  diseases  in  which  blood  in  the  dejections  may 
appear,  are  included  all  diseases  leadmg  to  a  great  wasting  of 
the  organism,  as  morbus  Brightii  chronicus,  caries,  chronic  diar- 
rhoea, etc.  There  almost  always  appear  in  such  patients, 
before  death,  obstinate,  waterv  diarrhoea,  during  which  bloodv 


DISRASKS  OF  THE  STOMACH   AND   IXTliSTI  X  ES  l8l 

dejections  are  also  occasionally  observed  (althongh  seldom), 
probably  because  of  rupture  of  the  amyloid  degenerated  vessels. 

Cases  of  the  second  category,  that  is,  intestinal  haemorrhages 
because  of  the  hindered  reflux  of  venous  blood,  occur  in  children 
in  extremely  rare  instances,  like  those  diseases  of  the  liver  upon 
which  intestinal  h?emorrhages  most  frequently  depend.  As  bloody 
dejections  in  such  cases  play  a  secondary  role,  we  shall  not  speak 
further  about  them. 

To  the  third  class  belong,  first,  various  ulcerations  of  the 
mucous  membrane  of  the  small  intestines.  Inkers  are  usually 
caused  by  general  affections  of  the  organism,  and  most  often  by 
typhoid  fever  and  tuberculosis.  The  diagnosis  of  these  ulcers  is 
not  always  possible,  as  they  do  not  invariably  cause  pronounced 
symptoms.  While  it  is  true  that  they  are  generally  associated 
with  diarrhoea,  still  the  latter  does  not  depend  upon  the  ulcers, 
but  rather  upon  the  concomitant  catarrh.  In  case  the  catarrh  be 
absent,  then,  despite  the  ulcers,  there  may  be  constipation,  as 
happened  in  observations  of  tubercular  ulcers  of  the  bowels*  by 
Rilliet  and  Barthez.  The  same  authors  noticed  the  fact  that  the 
gravity  of  the  diarrhoea  does  not  depend  upon  the  number  of 
ulcers. 

Pain  in  a  limited  part  of  the  abdomen,  increasing  on  pres- 
sure, is  also  sometimes  observed  in  ulcers,  but  it  may  be  absent, 
depending  not  upon  the  ulcers  themselves,  but  upon  the  limited  in- 
flammation of  the  peritoneum  corresponding  to  the  ulcer.  Pus 
is  formed  in  small  amounts,  being  so  intimately  mingled  with 
the  dejecta  that  it  is  impossible  to  be  detected;  so  that  in  view  of 
the  enumerated  considerations  bloody  dejections  are  the  most 
certain  sign  of  intestinal  ulcers,  if  they  appear  during  typhoid  or 
tuberculosis. 

It  is  self-evident  that  this  sign  is  far  from  being  constant, 
because  intestinal  ulcers  seldom  give  rise  to  the  appearance  of 
hsemorrhages. 

Pure  blood,  mingled  in  greater  or  less  quantity  with  non- 
copious,  mucous  stools,  voided  with  violent  tenesmus  and  abdom- 
inal pains,  points  to  an  affection  of  the  large  bowels,  and  espe- 
ciallv  of  the  rectum.     Such  stools  are  observed  in  acute  follicu- 


*K!i!dcrkraiiI;licitcn  III.,  s.  993. 


l82  DISKASES  OF  THE  STOMACH   AND   IXTESTIN'ES 

lar  enteritis,  dysentery  and  follicular  ulcers  of  the  lower  portion 
of  the  bowels   (chronic  dysentery). 

Symptoms  of  acute  follicular  enteritis  have  been  already 
mentioned  in  the  part  on  the  diarrhoea  of  nurslings. 

Dysentery,  like  any  other  infectious  disease,  appears  in 
exceedingly  various  forms.  There  are  different  transitory  forms 
between  the  mildest  cases,  terminating  with  convalescence  in  two 
or  three  days,  and  even  in  a  few  hours,  for  instance,  after  the 
first  dose  of  castor-oil,  and  the  gravest,  leading  to  death  in  a  few 
days. 

For  the  sake  of  convenience  three  varieties  may  be  described ; 
mild,  medium  and  severe.  The  general  symj^toms  of  all  these 
forms  are;  small,  frequent,  nuicous  stools,  tenesnnis  and  abdom- 
inal pain. 

Mild  fonns  do  not  differ  in  their  symptoms  and  course  from 
the  medium  and  mild  cases  of  follicular  enteritis  (page  165), 
the  only  point  is  that  dysentery  is  an  epidemic  and  infectious  dis- 
ease, while  follicular  enteritis  is  not  contagious,  being,  therefore, 
called  sporadic  bloody  diarrhcea. 

As  the  most  characteristic  peculiarity  of  the  mild  form  of 
dysentery  we  shall  only  ]X)int  out  that  Nirc  Dtiicoiis  stools  ore 
cither  entirely  absent,  or  they  apf^ear  alternately  with  paf^-like 
jceeal  matter  several  times  a  day. 

In  the  /;;//(/  form  the  number  of  evacuations  ranges  from  ten 
to  twenty  daily.  Hiey  are  ordinarily  composed  of  pure  mucus, 
green  or  white,  stained  with  blood.  The  tenesmus  is  consider- 
able. Faecal  dejections  do  not  ap])ear  for  two  or  three  days  in 
succession,  but  may  be  produced  by  a  laxative.  In  the  beginning 
of  the  disease  elevation  of  tem])erature  is  noticed  for  a  couple 
of  days.  The  abdomen  is  painless  u]:)on  pressure,  or  the  pain  is 
slight,  being  limited  to  a  small  area  in  the  region  of  the  left  iliac 
fossa.  Collaf'se  is  absent.  After  about  eight  to  twelve  davs  the 
period  of  amelioration  occurs,  that  is,  all  symptoms  gradually 
abate,  while  there  begins  to  appear,  oftener  with  each  twentv- 
four  hours,  fsecal  matter  together  with  mucus,  and,  after  about 
two  or  three  weeks,  the  muco-bloody  diarrhoea  becomes  a  sim- 
ple one,  and,  after  one  or  two  weeks  more,  everything  reaches 
tlie  normal  standard. 

The  ^i;;-fl7r  variety  of  dysentery  depends  upon  the  formation 


DISEASKS  OF  TllK  STO.MAC  11    AM)    1  N  ri':STI  .\  HS  183 

of  a  clij)htheritic  exudate  on  the  inflamed  mucous  membrane,  be- 
ings characterized,  not  so  much  by  the  initial  hij^h  fever  and  the 
too  frequent  pulse  and  violent  straining-,  as  by  symptoms  of  im- 
minent collapse  and  considerable  painf^tlness  of  the  abdomen  on 
pressure  over  the  course  of  the  colon,  especially  of  the  colon 
descendens.  Faecal  dejections  are  absent  for  several  days  in  suc- 
cession, being  difficult  to  obtain  even  after  a  laxative.  Red  de- 
jections, like  "washed  raw  meat"  and  consisting  of  evenly-stained, 
serous  fluid  mixed  with  mucous  lumps,  occur  only  in  grave  cases 
of  dysentery. 

If  the  patient  survives  the  acute  period  (two  or  three  weeks), 
then  the  further  course  becomes  considerably  protracted, 
so  that  the  picture  of  chronic  diarrlnra  is  obtained.  The  i)atient 
moves  the  bowels  not  very  often,  about  six  or  eight  times  during 
twenty-four  hours,  the  evacuations  being  very  offensive,  watery  or 
pap-like,  mingled  with  purulent  mucus,  while  there  are 
usually  colic-like  pains  in  the  abdomen  together  with  tenesmus. 
By  the  persistent  tenesmus  and  admixture  of  purulent,  sometimes 
sanious,  mucus  in  the  faecal  dejections,  chronic  dysentery  differs 
from  a  common  chronic  intestinal  catarrh,  in  which  the  evacua- 
tions, although  also  offensive,  are  not  often  accompanied  by  ab- 
dominal pains  (see  the  section  on  the  Chronic  Catarrh  of  the  In- 
testines, page  168). 

The  duration  of  chronic  dysentery  ranges  approximately 
from  two  to  six  months,  finally  terminating  in  the  majority  of 
cases,  with  recovery. 

[At  present  two  forms  of  dysentery  are  distinguished  :  One 
due  to  an  amoeba  and  the  other  to  a  bacillus  (bacillar  dysentery 
and  amoeba  dysentery).  The  difference  between  these  two  forms 
is  the  following : 

The  amoeba  dysentery  develops  endeniically.  especially  in 
hot  countries,  pursues  a  chronic  course  with  remissions  and  exa- 
cerbations, and  is  often  complicated  u'ith  abscesses  of  the  //z'^r,* 
Pathologically  it  is  characterized  by  the     necrosis     starting     in 


*Amberg**  says  that  abscess  of  the  liver,  which  is  rather  a  frequent 
complication  of  amoebic  dysentery  in  aduks  seems  to  be  of  very  rare  occur- 
rence in  children.  Twelve  cases  of  liver  abscess  in  children  following 
dysentery  are  reported.  Kruse  and  Pasqualc  found  Charcot-Leyden  crys- 
tals in  the  material  taken  from  liver  abscesses. 

**Biil.  Johns  Hof^kius  Hosp..  Vol.  XH..  1901,  pp.  355-35i^- 


184  DISEASES  OF  THE  STOMACH   AND  INTESTINES 

the  submucosa.  The  cause  is  amoeba  coli  first  described  by 
Loesch,  of  St.  Petersburg,  in  187 1. 

The  bacillar  form  occurs  epidemically  and  in  any  country, 
rather  than  particularly  m  torrid,  it  always  has  an  acute 
course,  seldom  becoming  chronic  and  does  not  lead  to  the  forma- 
tion of  abscesses  of  the  liver.  The  necrosis  appears  in  the  upper 
layers  of  the  intestinal  mucosa  and  gradually  extends  deeper. 

The  cause  of  this  form  is  bacillus  dysenteriae,  first  described 
in  Japan  ( Tokio)  by  Kitasato's  assistant,  Shiga,  in  1897- 1899,  ^.nd 
more  fully  by  Kruse,  in  1901,  so  that  this  bacillus  is  known  under 
the  name  of  the  Shiga-Kruse  bacillus. 

The  diagnosis  between  these  two  forms  of  dysentery  may  be 


Fig.   17 — Amoeba  coli    (Losh). 

cjuite  easily  effected  upon  consideration  of  the  symptoms  men- 
tioned, but  the  chief  factors  in  the  diagnosis  are,  of  course,  the 
bacteriologic  findings ;  in  the  amceba  dysentery — of  amoeba 
Loschii ;  or  the  Shiga-Kruse  bacillus  in  the  other  variety. 

Losch's  observations  have  been  confirmed  all  over  the  world ; 
in  America,  by  Osier,  Councilman  and  Lafleur,  Harris  and  others. 
William  Osier  was  the  first  to  describe  amoeba  coli  in  1890,  and 
his  investigations  have  been  followed  b}-  many  other  excellent 
articles  and  monographs. 

The  amoebse  are  from  12  to  36  mikro-millimeters  in  diam- 
eter (even  50  in  "giant"  amrebas),  and  consist  of  protoplasm 
which  always  contains  a  nucleus.  The  protoplasm  is  made  up  of 
an  outer  zona  ("ectosarc"  or  "ectoplasm")  and  an  inner  one 
("endosarc"  or  "entoplasm").     The  latter  may  be  distinguished 


DISEASES  OF  THE  STOMACH   AND   IXTESTINKS  185 

from  the  former  ("ectosarc")  by  (a)  its  highly  refractive  power; 
(b)  by  containing  foreign  bodies  (bacteria,  granular  detritus, 
leucocytes,  red  blood  corpuscles,  large  and  small  vacuoles).  The 
difiference  between  ectoplasm  and  entoplasm  is  best  seen  during 
the  movements  of  the  amoeba.  The  auKieba  movement  undergoes 
by  throwing  out  protoplasmic  arms — so  to  speak — thus  assum- 
ing different  forms.  They  are  readily  stained  with  methylene 
blue  and  toluidine  blue ;  the  endosarc  of  the  amceba  taking  the 
stain  at  once,  the  ectosarc  only  after  the  lapse  of  several  min- 
.utes.*     (Fig.  17.) 

In  the  bacillar  form  of  dysentery  the  bacteriologic  findings 
are  different ;  here  the  Shiga-Kruse  bacillus  looks  like  the  coli- 
bacillus. It  stains  with  any  of  the  anilin-stains,  while  the  poles 
take  a  deeper  tint  than  the  middle  of  the  microbe.  It  does 
not  take  the  Gram,  and  does  not  possess  automatic  movements 
(although  Shiga  pointed  out  wdiat  he  believed  to  be  a  slight  mo- 
tility). It  does  not  form  spores  and  grows  on  any  nutritive  me- 
dium. It  does  not  liquefy  gelatin  and  is  agglutinated  by  the  serum 
of  the  patient. 

When  the  pure  culture  is  injected  in  the  rectum  of  some 
animals,  dysentery  may  be  produced,  but  Rosenthal,**  of  Moscow^ 
points  out  that  cats  are  very  often  immune  to  bacillar  dysentery^ 
but  never  to  the  amoebic  form,  which  is  always  pathogenic  for 
cats.  This  point  also  shows  the  great  difference  between  the  char- 
acters of  these  two  forms  of  dysentery.  Shiga's  discovery 
was  thus  confirmed  not  only  in  Germany  by  Prof.  Kruse,  but  also 
in  Russia  (Moscow  at  least),  and  in  America,  Flexner***  de- 
scribed a  dysenteric  bacillus  very  similar  to  Shiga's,  although  ap- 
parently not  entirely  identical  to  the  latter.  Other  authors,  as 
for  instance,  Jiirgens,****  claims  that  the  cause  of  dysentery  lies 
in  many  bacilli,  and  not  only  in  the  Shiga-Kruse  type.  In  his 
twenty-six  cases  of  dysentery  Kruse's  bacillus  was  never  found, 
but  in  eighteen  cases  Flexner's  type  w-as  discovered. — Earle.  ] 

*See  Harris:  Amoebic  Dysentery  (Am.  Jour,  of  Med.  Sc,  1898,  April). 
**Zur  Aetiologie   der   Dysentery    (Dctit.  Med.   jyoeh.,   1903,  No.  6,  n. 
97,  etc. 

***P/j;7a.  Med.  Journal,  vi.,  1900,  p.  414. 

****Zur  Aetiologie  der  Ruhr.     (Deut.  Med.  IVoch.,  1903,  No.  46). 


l86  DISEASES  OF  THE  STOMACH   AND  INTESTINES 

Pure,  red  blood  from  the  anus  in  small  children  always  dis- 
charges in  small  amount — a  few  drops. 

The  usual  cause  of  such  a  haemorrhage  is  constipation  with 
the  formation  of  solid  faeces  which  tear  the  mucous  membrane 
during  their  passage  through  the  anus. 

For  the  diagnosis  a  simple  inspection  of  the  stools  suffices ; 
the  latter  consists  of  solid,  dry  lumps  of  dark-brown  or  white 
color  (in  small  children  when  the  diet  is  exclusively  milk),  some 
parts  being  stained  with  drops  of  unchanged  blood.  The 
evacuation  is  somewhat  painful,  being  associated  with  violent 
straining  (that  is,  with  contraction  of  the  abdominal  muscles,  but 
not  tenesmus  in  the  rectum)  ;  older  children  complain  of  slight 
burning  in  ano  after  the  passage  of  stools,  because  of  rupture  of 
the  mucous  membrane. 

A  slight  haemorrhage  may  also  occur  with  tluid,  but  acrid. 
dejections,  namely,  in  the  case  of  formation  of  excoriations  on 
the  mucous  membrane  of  the  rectum,  being  analogous  to  those  of 
the  upper  lip  during  coryza.  These  excoriations  usually  occupy 
the  posterior  wall,  being  associated  with  eczema  around  the  anus, 
which  aids  the  diagnosis. 

With  these  insignificant  and  ra])idl\ -healing  excoriations, 
one  must  not  confound  extremely  obstinate  and  jjainful  tissiires  of 
the  anus,  about  which  1  shall  s])eak  in  the  article  on  Constipation 
(page  195). 

The  appearance,  after  each  defecation,  of  some  drops  of  pure 
"blood  from  the  anus,  but  in  the  absence  of  constipation  and  pains 
during  the  act  of  defecation,  serves  as  a  certain  sign  of  a  polypus 
in  the  rectum.  Digital  examination  detects  in  such  cases,  some- 
what higher  then  the  point  of  the  internal  sphincter  on  the  pos- 
terior wall  of  the  rectum,  a  small  (the  size  of  a  cherry),  soft, 
elastic,  easily-bleeding  pedunculated  tumor.  In  some  cases  the 
polyp  comes  out  with  every  evacuation  of  the  bowels  and  thus 
may  simulate  a  small  prolapsus  ani.  It  suffices  to  know  this 
fact  in  order  to  determine  the  disease  during  the  digital  exam- 
ination. Similar  bloody  stools  (that  is,  associated  with  soft  de- 
jections and  without  pains)  depend  not  only  upon  polypus,  but 
on  ulcers  in  the  rectum. 

In  prohipsus  ani  there  extrudes  a  pear-shaped  or  cylindrical 
tumor,  of     purple-red     color,    easily    bleeding.       On  the  top  of 


DISEASES  OF    lllK  STOMACH   AND    I  XTESTIN' KS  18/ 

the  tumor  there  is  an  opening-  througli  which  it  is  eas\-  to  pass 
the  finger. 

iJetween  the  tumor  and  the  anal  edges  there  is  a  ring-shaped 
sht.  through  which  it  is  easy  to  reach,  with  the  finger,  the  point 
of  the  fold  of  the  everted  intestinal  wall.  The  tumor  is  easily 
reduced  in  recent  cases  and  when  it  does  not  exceed  the  size  of 
a  common  pear.  It  would  be  difficult  to  confuse  prolapsus  ani 
'vvuth  anything  else. 


SEMEIOLOGY  OF  CONSTIPATION. 

Constipation,  as  a  temporary  or  subsidiary  symptom,  occurs- 
very  often  during  many  febrile  and  other  diseases,  but  here  we 
have  in  view  onlv  such  cases  in  which  constipation  occurs  as  a 
single,  or,  at  least,  as  the  chief  s\  inplom  and  is  at  the  same  time 
of  uncertain  duration.  This  is  the  so-called  habitual  constipation,. 
most  often  occurring  in  children  of  the  first  two  years  of  life. 

The  child  moves  the  bowels  during  the  first  months  of  life,, 
when  fed  only  by  the  breast,  two,  three,  or  four  times  during 
twenty-four  hours.  Hut  ihc  (|uestion  arises  here  whether  one- 
may  speak  of  a  nursing-child  being  constipated  if  he  has  only 
one  passage  which,  however,  is  copious,  of  normal  ct^lor  and  of 
mustard-like  consistency?  Some  authors  give  an  affirmative  an- 
swer to  the  question,  although,  from  such  a  point  of  view,  any 
criterion  for  judging  where  constipation  terminates  and  where 
normal  activity  of  the  bowels  begins,  is  lost,  because  a  single 
evacuation  during  twenty-four  hours  may  be  more  copious  than 
two  or  three  at  shorter  intervals  put  together.  Therefore,  it 
seems  to  be  more  correct  to  base  the  diagnosis  of  constipatioir 
on  the  quality  of  the  stools  and  on  the  appearances  which  accom- 
pany the  act  of  defecation. 

The  function  of  the  intestines  in  small  children,  as  well  as 
in  grown  persons,  depends  u])on  the  individuality.  There  are 
children  who  move  the  bowels  every  second  day ;  nevertheless 
their  stools  always  are  of  normal,  jelly-like  consistency  and  of 
yellow  color,  the  general  condition  being  excellent ;  so  that  there 
are  no  reasons  to  speak,  in  such  cases,  about  constipation. 

If  the  quantity  of  the  child's  stools  does  not  correspond  to- 
its  organization,  then  the  retention  of  products  of  waste  will  be 
manifested  by  certain  symptoms,  in  the  presence  of  which  we 
say  that  the  child  is  suffering  from  habitual  constipation.  These 
symptoms  may  be  as  follows : 

(i)     The  stools  assume  solid  consistency  and  contain  formed 


SEMEIOLOGY    OF    CONSTIPATION  189 

faecal  matter,  soft  and  sausage-like  (in  mild  cases),  or,  in  graver 
cases,  in  entirely  solid  lumps  of  whitish  color. 

(2)  The  act  of  defecation  is  performed  by  the  visible  par- 
ticipation of  the  abdominal  muscles ;  the  child  strains,  the  face  be- 
comes red  and  sometimes  drenched  with  perspiration. 

(3)  During  defecation,  or  shortly  before  the  act.  abdominal 
pains  occur  so  that  the  child  becomes  restless  and  sometimes  even 
convulsions  follow. 

(4)  The  abdomen  is  distended,  but  usually  is  painless  u])on 
pressure,  (it  is  very  difficult  in  a  nursling  to  feel  the  hard  lumps 
of  fseces  through  the  abdominal  walls). 

(5)  The  evacuations  occur  in  mild  cases  once  a  day  or 
•every  other  day,  in  severe  cases  after  two  or  four  days,  and  then 
the  retention  of  the  stools  may  be  the  cause  of  fever. 

In  older  children  constipation  is  usually  accompanied  bv 
loss  of  appetite,  distension  of  the  abdomen,  sometimes  colicky 
pains,  as  well  as  wMth  languidness,  headache  and  occasionally  by 
fever,  so  that  it  may  simulate  chronic  peritonitis,  in  which  there 
also  exists  some  inclination  to  constipation,  associated  with  the 
-distended  abdomen,  and  colicky  pains  and  sometimes  with  fever. 

The  diagnosis  here  is  not  always  easy.  It  is  based  on  the 
-abdomen  being,  in  chronic  peritonitis,  not  only  distended,  but 
also  toisc.  the  constipation  often  alternates  with  diarrhoea,  the  ac- 
^cumulation  of  fluid  in  the  peritoneal  cavity  is  noticed,  and  in  more 
pronounced  cases  one  succeeds  in  feeling  limited  tumors 
in  the  abdomen  due  to  inflammatory  thickening  of  the  peritoneum 
and  concretions  between  the  intestinal  segments ;  then  also  the 
general  condition  of  the  nutrition  exhibits  a  greater  degree  of 
wasting  than  in  acute  or  chronic  constipation. 

If  constipation  is  associated  with  pronounced  fever,  gen- 
eral weakness  and  headache,  such  a  symptom-complex  lasting 
several  days,  then  it  is  easy  to  mistake  the  disease  for  a  beginning 
typhoid. 

In  other  cases  constipation  is  accompanied  by  cerebral 
symptoms,  as  vomiting,  headache,  slight  elevation  of  tempera- 
ture, retarded  and  somewhat  irregular  pulse,  dilatation  of  the 
pupils,  somnolence — all  these  symptoms  lasting  a  few  days  and 
rapidly  disappearing  after  a  copious  evacuation  produced  by  a 
laxative.     (Compare  two  cases  described  in  the  text-book  of  Bar- 


IQO  SEMEIOLOGY    OF    CONSTIPATION 

thez  and  Sanne,  Vol.  II.,  page  532,  regarding  a  nine-year-old  girl 
and  a  boy  aged  twenty-seven  months.) 

Jn  one  of  our  cases,  a  boy  eight  years  old,  fever  simulated 
intermittent  for  two  weeks,  with  the  morning  elevations  up  tO" 
39-5  degrees  C.  (103  degrees  F.)  and  evening  to  40.8  degrees 
C.  (105.4  degrees  F.),  but  not  entirely  regular  and  not  daily.  It 
did  not  yield  to  (juinine  but  disappeared  after  a  glass  of  laxative- 
lemonade. 

With  the  exception  of  such  rarities,  the  diagnosis  of  con- 
stipation is,  of  course,  not  difficult,  but  the  main  thing  is  to  find 
tlic  cause  of  the  constipation  in  each  case,  for,  only  then,  a  rational 
therapy  is  possible. 

The  cause  of  constipation  in  small  children  must  be  looked 
for  either  in  the  child  himself,  or  in  peculiarities  of  the  food. 

Children  are  met  with  in  whom  constipation  seems  to  de- 
pend upon  a  too  thorough  digestion  of  the  breast  milk.  They 
seldom  move  the  bowels  because  the  milk  affords  but  little  resi- 
due for  the  formation  of  faeces,  and,  until  a  sufficient  quantity  of 
the  latter  accumulates,  the  watery  parts  are  absorbed  in  the  large 
bowels,  the  dejections  becoming  solid,  thus  making  the  act  of 
defecation  more  difficult.  Superfluous  formation  of  flatulence 
is  not  noticed  during  such  a  constipation,  therefore,  absence  of 
meteorism  and  an  excellent  general  condition  arc  peculiar  to  it. 
The  child  appears  healthy  in  every  regard  and  increases  in. 
weight  more  than  one  would  expect,  that  is,  he  becomes  fat. 

Changing  the  wet-nurse  does  not  remove  such  a  constipa- 
tion. Relief  is  best  accomplished  by  changing  the  diet  of  the 
child,  giving  for  instance,  bouillon  or  a  few  spoonfuls  of  plain^ 
cool  water.  French  authors  suppose  that  the  cause  of  such  an 
inherited  habitual  co>istipatiou  is  defect  of  development  of  the 
large  intestines,  namely,  increase  of  the  dimensions  and  of  the 
number  of  the  curvatures  of  the  sigmoid  flexure  in  such  chiKlren. 

In  other  series  of  cases  constipation  depends  upon  the  weak- 
ness or  torpidity  of  the  intestinal  musculature,  which  may  be  sus- 
pected during  constipation  in  children  who  are  in  general  weak 
and  anaemic,  and  above  all  m  rachitic  ones,  in  whom  the  whole 
musculature  is  feeble.  The  same  cause,  that  is,  insufficiency  of 
the  peristaltic  activity  of  the  bowels,  we  have  a  right  to  suspect 


SEMKIOLOGV    (,)]■'    CONSTIPATION  I9I 

(luriiii;-  clironic  hytlrocephalus,  as  well  as  in  other  cerebral  dis- 
eases. 

What  influence  is  effected,  in  infantile  constipation,  by  the 
hereditary  disposition  in  cases  of  chronic  diarrhtjea  in  the  mother^ 
it  is  hard  to  sa}",  because  this  influence  is  far  from  being  mani- 
fested in  all  cases,  and  especially  if  the  child  is  fed  by  a  wet- 
nurse. 

A  cause  of  constipation  in  nurslings,  existing  from  the  very 
first  weeks  of  life,  may  be  coiii^cnital  contracture  of  the  entire 
rectum,  or  of  the  anus.  Xoriually  one  may  introduce  the  little 
finger  into  the  anus  of  a  nursling  without  great  difficulty ;  when, 
however,  this  is  contracted  the  examination  does  not  succeed 
altogether,  or  only  with  great  difficulty.  This  cause  of  constipa- 
tion, in  spite  of  its  easy  recognition,  very  often  remains  undis- 
covered, only  because  physicians  usually  do  not  resort  to  exam- 
ination of  the  anus  by  the  finger,  notwithstanding  this  should  be 
done  in  all  cases  of  chroiiic  constipation  in  children.  In  illustra- 
tion I  will  describe  the  following  two  cases : 

A  child,  aged  ten  months,  until  nine  and  a  half  months  was 
nursed  by  the  mother's  breast  and  was  all  the  time  inclined  to 
constipation,  notwithstanding  the  stools  having  been  of  normal 
pap-like  consistency.  The  constipation  became  so  obstinate  dur- 
ing the  two  weeks  after  weaning  that  a  laxative  had  to  be  given 
several  times,  and  for  the  last  three  days  the  child  did  not  move 
the  bowels  at  all,  notwithstanding  the  fact  that  he  was  given 
several  tablespoonfvils  of  Hunyadi.  The  abdomen  was  distended 
and  a  somewhat  dull  sound  was  obtained  on  percussion  of  the  left 
hypogastric  region.  The  child  became  restless,  there  was  vom- 
iting twice  in  the  last  twenty-four  hours ;  he  would  strain  several 
times,  but  without  any  result.  Hoping  to  find  lumps  of  solid 
faeces  in  the  lower  portion  of  the  rectum  I  resorted  to  an  exam- 
ination with  the  finger,  when  an  entirely  different  cause  of  the 
constipation  was  found.  At  a  point  one  centimeter  from  the 
external  anal  opening  the  finger  met  a  laminated  septum  with  a 
small  opening  in  the  center.  The  end  of  the  small  finger  passed 
with  great  difficulty,  while  a  sensation  was  obtained  as  if  the 
finger  was  bound  by  a  thin,  but  strong,  india-rubber  cord.  The 
examination  caused  the  child  severe  pain. 

We  thus   found  here   a  congenital   stricture  of   the   rectum 


192  SEMEIOLOGV    OF    CONSTIPATION 

caused  by  the  incomplete  disappearance  of  the  septum  which 
arises  at  a  certain  period  of  embryonic  life  when  the  rectum  de- 
velops. As  long  as  the  child  was  fed  by  the  breast  the  stools 
were  thin  enough  to  pass  the  small  opening,  although  not  very 
freely.  However,  after  weaning  the  stools  became  somewhat  more 
solid,  and  the  presence  of  the  septum  caused  a  very 
obstinate  constipation. 

In  another  case,  in  a  child  several  weeks  old,  although  the 
dejections  took  place  several  times  a  day,  yet  always  in  very  small 
cjuantities  and  were  associated  with  straining.  The  color  and 
the  consistency  of  the  evacuations  appeared  entirely  normal, 
mucus  being  absent.  In  this  case  there  was  a  stricture  of  the 
anus  itself  which  was  so  narrow,  because  of  the  fold  of  the  mu- 
cous membrane  which  covered  its  anterior  segment,  that  a  com- 
mon catheter  could  hardly  be  passed. 

Of  constipation  due  to  stricture  or  obstruction  of  the  upper 
portions  of  the  bowels  we  shall  speak  in  the  next  section. 

In  weaned  or  bottle-fed  babies,  as  well  as  in  elder  children, 
digital  examination  sometimes  detects  the  cause,  and,  simultane- 
ously, the  consequence  of  the  constipation  in  the  presence  of  vo- 
luminous dry  lumps  within  the  anus  itself.  Despite  the  strongest 
straining  these  lumps  cannot  pass  the  external  opening  of  the  rec- 
,tum  because  of  their  great  size.  It  is  evident  that  enemata  are, 
in  such  cases,  not  altogether  applicable,  because  the  end  of  the 
instrument  immediately  becomes  blocked  by  the  faeces,  and  laxa- 
tives are  also  without  any  result  until  the  fcxcal  matter  is  removed 
by  mechanical  means  or  simply  by  the  finger. 

If  the  child  suffered  from  constipation  while  nursing  one  wet- 
nurse,  and  becomes  relieved  of  it  with  the  change  to  another, 
then  we  may  positively  suspect  the  cause  of  constipation  in  some 
peculiarity  of  the  uiilk.  What  these  peculiarities  are  we  do  not 
know,  but  we  infer  them  to  be  either  in  deficiency  of  fat,  or  in 
superfluity  of  casein.  Such  milk,  known  to  the  laity  as  heavy 
milk,  sometimes  occurs  in  women  suffering  from  habitual  con- 
,stipation,  as  well  as  in  those  who  had  nursed  for  a  long  time  (old 
milk)  and  also  in  aged  women. 

The  cause  of  constipation  may  also  be  deficiency  of  milk  or 
watery  milk.  In  both  these  cases  the  child  starves  chronicallv, 
that  is,  there  is  little  increase  in  weight,  or  it  grows  thin  and 


SEMEIOLOGV    OF    CONSTIPATIOX  I93 

suffers  from  constipation  because  of  want  of  material  for  the 
formation  of  f?eces. 

Besides  wasting-  there  are  also  peculiar  to  such  a  constipa- 
tion, restlessness  of  the  child  (he  cries  very  much  because  of  hini- 
ger)  and  scanty  micturition. 

As  scales  are  very  rarely  to  be  found  in  our  nurseries,  and 
as  it  is  not  easy  to  note  with  the  eye  a  slowly  progressive  wasting, 
therefore  very  often  it  happens  in  practice  that  the  constant  cry 
of  the  child  is  ascribed  to  colics  and  is  accordingly  treated  by  dif- 
ferent drugs.  If,  in  the  absence  of  eructation,  scanty  micturition 
and  constipation  (instead  of  dyspeptic  stools)  the  cause  of  the 
cry  may  be  supposed  to  be  a  lack  of  milk,  then  it  is  very  easy  to 
become  convinced  of  the  correctness  of  such  a  proposition.  The 
child  has  only  to  be  given  cow's  milk  when  he  will  be  calmed  for 
a  few  hours.  It  is,  however,  not  difficult  to  prove,  even  without 
scales,  that  the  wet-nurse  has  but  little  milk.  If  there  is  enough 
milk,  then,  immediately  after  the  child  has  been  nursed,  the  milk 
should  gush  from  the  sucked  breast,  when  pressed,  in  several 
streams ;  on  the  contrary,  if  the  milk  can  be  squeezed  out  only 
in  drops,  then  it  means  there  is  but  little  of  it. 

As  a  frequent  cause  of  constipation  should  be  mentioned  the 
nourishment  of  children  with  starchy  siLbstanccs  which  do  not 
"become  well  digested  during  the  first  months  of  life,  and  then  the 
faeces  will  show  very  much  starch  which  had  not  been  converted 
into  dextrine  and  sugar  in  the  bowels.  Such  a  constipation 
quickly  yields  to  a  proper  diet  (starchy  food  must  be  forbidden). 

In  bottle-fed,  as  well  as  in  recently-weaned,  children  the  most 
common  cause  of  very  obstinate  constipation  has  to  be  looked 
for  in  the  inunoderate  use  of  cow's  milk.  Constipation  is,  in  such 
cases,  characterized  by  the  appearance  of  faintly-stained,  some- 
times entirely  white,  as  in  catarrhal  jaundice,  solid  and  even 
entirely  dry  faeces  resembling  curd. 

The  history  shows  that  the  child  drinks,  during  the  twenty- 
four  hours,  about  eight  or  ten  glasses  of  milk.  Practically  it  is 
very  important  to  note  that  such  immense  quantities  of  milk  are 
employed  by  children  only  if  they  are  given  the  milk,  not  alone  as 
food,  but  also  as  a  drink,  during  the  day  and  night.  Some  chil- 
dren drink  and  eat  nothing  else  but  milk.  In  the  treatment  of 
such  constipations  an  absolute  abstinence  from  milk  is  tuineces- 


194  SEMEIOLOGV    OF    CONSTIPATION 

sary.  It  is  sufficient  to  forbid  its  use  as  a  drink,  especially  at 
night-time;  this  alone  will  decrease  the  amount  of  milk  by  three 
or  four  glasses,  while  the  appetite  will  increase.  He  will  also  eat 
other  food,  and  the  purpose  of  treatment  will  thus  be  accom- 
plished by  this  measure  alone,  and  at  the  same  time  the  correct- 
ness of  the  diagnosis  will  be  confirmed.  If  the  child  is  too  small 
to  be  fed  with  varied  ioo<\,  the  constipation  with  white  dejections 
being  persistent  in  spite  of  the  diminution  of  the  quantity  of  milk,, 
then  the  latter  must  be  given  half-diluted  with  boiled  water. 

Constipation  is,  after  two  years,  much  less  frequently  ob- 
served, the  food  being  more  varied 

Habitual  constipation,  together  with  loss  of  appetite,  is  usu- 
ally acc()m])anicd  b\-  anremia  (see  page  112)  and  neurasthenia.  In 
other  cases  it  is  accompanied  by  symptoms  of  chronic  gastritis  or 
depends  upon  uniform,  very  dry,  food  (in  the  poorer  class  of 
people,  potatoes  and  bread)  or  milk,  or  astringent  medicines, 
among  which  are  included  some  iron  preparations. 

The  cause  of  constipation  in  older  children  may  be  the  had 
habit  of  delaying  the  desire  for  a  stool.  Such  a  habit  results  in 
distension  of  the  lower  portion  of  the  large  bowels,  being  neces- 
sarily accompanied  by  weakening  of  the  tone  of  the  intestinal 
musculature.  An  important  influence  is  sometimes  effected  by  a 
sedentary  mode  of  life  and  forced  mental  work. 

If  no  setiological  reason,  either  in  the  food,  in  the  mode  of 
life,  neurasthenia,  intestinal  catarrh,  etc.,  can  be  found  to  account 
for  constipation,  then  it  remains  only  to  suppose  atony  of  the 
large  bowels  or  rectum  owing  to  anomaly  of  innervation  of  these 
portions  of  the  intestines,  or  thinness  of  the  intestinal  wall. 

Constipation  often  develops  in  children  immediately  after  a 
chronic  diarrhoea  has  stopped  (has  been  cured).  Constipation 
is  in  such  cases  either  temporar}^  disappearing  in  a  few  weeks  by 
itself,  or  it  may  be  constant.  Its  cause  is  chronic  catarrh  of  the 
large  bowels.  If  the  constipation  was  preceded  by  grave  dysen- 
tery, then  one  may  suspect  the  formation  of  cicatricial  adhesions 
narrowing  the  lumen  of  the  bov/els. 

In  children  from  one  up  to  three  years  old  there  occurs 
another  characteristic  form  of  constipation,  the  typical  feature  of 
which  is  that  the  child  is  afraid  of  moving  the  bowels,  because 
this  causes  him  severe  pain.     The  child  attempts  by  all  means  to 


OBSTINATE    CONSTIPATION     AND     VOMITING  I95 

refrain  from  this  act ;  when  seated  on  the  toilet-chair  he  jumps 
up,  cries,  etc.  Such  constipation  almost  always  depends  upon  an 
ajial  fissure — fissura  ani.  One  need  only  to  separate  the  buttocks 
of  the  child  and  inspect  its  anus,  in  order  to  learn  the  correctness 
of  such  a  proposition.  The  fissure  is  usually  located  between  the 
mucous  membrane  and  the  skin  along  one  of  the  radiated  folds 
surrounding  the  anus. 

DISEASES  CHARACTERIZED  BY  OBSTINATE  CONSTI- 
PATION AND  VOMITING. 

Intestinal  obstruction,  ilc\is,  s.  volvidits,  whatever  the 
cause  ma}'  be,  is  always  evidenced  by  obstinate  constipation,  in- 
coerc'ble  vaunting  (at  first  of  bile,  and  later  it  may  be  faecal)  and 
by  a  sudden  development  of  meteorism;  then  follows  cardiac  fail- 
u]  e  with  fatal  collapse,  unless  the  obstacle  be  removed. 

The  causes  of  intestinal  obstruction  in  childhood  are  far 
from  being  so  various  as  in  grown  people,  therefore  the  diagnosis 
is  comparatively  easier. 

In  new-born  children  the  only  causes  of  intestinal  obstruc- 
tion are  inherited  defects  of  development,  depending  most  fre- 
Cjuently  upon  atresia  ani  (closure  of  the  anal  opening)  and  rarely 
obliteration  of  the  lumen  of  the  small  intestines. 

Obstruction  of  the  anus  is  not  dit^cult  to  recognize,  its  pres- 
ence being  suspected  on  account  of  retention  of  the  meconium 
and  obstinate  vomiting.  If  the  obstruction  refers  to  the  anal 
opening,  then  the  diagnosis  becomes  evident  by  mere  inspection, 
the  only  question  arising  is  the  height  at  which  the  blind  end  of 
the  rectam  termhiates.  In  order  to  detect  this  the  physician 
puts  his  hand  over  the  child's  perineum  and  from  the  size  of  the 
protrusion  of  the  perineum  at  the  normal  point  of  the  anus,  during 
the  cry,  one  may  get  an  idea  about  the  thickness  of  the  sheath 
which  separates  the  skin  from  the  blind  end  of  the  gut.  In  mild 
cases,  when,  for  instance,  the  entire  rectum  is  normally  developed, 
only  a  membrane  remaining  at  the  place  of  the  anus,  it  is  possible 
to  notice  the  protrusion  during  crying  even  by  the  eye. 

If  the  rectum  opens  into  the  bladder,  then  this  may  be  recog- 
nized by  the  meconium  being  mingled  with  the  urine. 

When  symptoms  of  intestinal  obstruction  occur  in  a  new-born 
v.ith  a  normally  developed  anus,  then  the  determination  of  the 


196  OUSTINATE    COxXSTIPATION     AND     VOMITING 

I>oint  of  occlusion  of  the  intestinal  lumen  is  performed  by  intro- 
ducing the  finger  or  the  sound.  If  the  rectum  be  found  passable, 
then  the  place  of  the  obstruction  must  be  looked  for  in  the  small 
bowels  (obliteration  of  the  large  intestines  rarelv  occurs).  In 
the  case  of  obstruction  of  the  duodenum  the  abdomen  is  not  alto- 
gether distended. 

Intestinal  obstruction  in  children  under  two  years  of  age,  as 
well  as  older  ones,  depends  not  infrequently  upon  a  strangulated 
INGUINAL  hernia.  A  Strangulated  hernia  is  not  difficult  to  diag- 
nose, because  symptoms  of  intestinal  obstruction,  as  rapidly-in- 
creasing meteorism,  colicky  abdominal  pains,  vomiting,  constipa- 
tion, etc.,  are  here  associated  with  local  symptoms  on  the  part  of 
the  hernia ;  the  latter  cannot  be  reduced  (while  before  it  was  easily 
reducible)  ;  the  hernial  tumor  becomes  gradually  more  and  more 
tense  and  simultaneously  there  appears  considerable  painfulness 
upon  pressure  on  the  tumor,  especially  near  the  strangulating  ring 
and  somewhat  higher.  If  the  physician  did  not  know  that  the 
child  had  had  a  hernia,  or  if  the  latter  had  been  absent  before,  but 
became  strangulated  at  the  first  prolapsus,  then  one  may  readily 
diagnosticate  infiammation  of  the  testicle  (orchitis)  on  the  ground 
of  the  red,  swollen,  very  painful,  inflamed  and  solid  (upon  palpa- 
tion), scrotum.  Such  a  mistake  is  possible  even  in  the  presence 
of  distinctly-developed  symptoms  of  intestinal  obstruction. 

The  picture  of  a  strangulated  hernia  in  childhood  may  be 
simulated  by  the  testicle  becoming  strangulated  in  the  in- 
guinal CANAL.  The  patient  complains  of  pain  in  the  groin  (small 
children  signify  this  simply  by  loud  crying  and  restlessness).  On 
examination  there  appears  in  the  region  of  the  inguinal  opening 
an  elastic,  smooth,  tense,  spherical  tumor,  very  painful  upon  press- 
ure ;  usually  vomiting  also  occurs ;  the  tumor  cannot  be  reduced ; 
in  short  the  symptoms  are  very  similar  to  those  of  a  strangulated 
hernia.  A  strangulated  testicle  difl:'ers  from  a  hernia,  first  by  the 
absence  of  progressively  increasing  meteorism,  and,  second,  by 
tlie  examination  of  the  scrotum  when  absence  of  the  tumor  may 
be  proven  (monorchismus). 

Moreover,  intestinal  obstruction  may  be  produced  not  only 
by  the  rarely  occurring  internal  strangulation  or  torsion  of  the 
intestines,  but  by  accuniulatio}i  in  the  intestines  of  foreign  bodies 
in  the  form,  for  instance,  of  cherry-stones,  clumps  of  ascarides, 


OBSTINATE     CO.XSIT  I'A  IK  ).\     AM)     \().\|  111  \C,  \ijj 

and  most  often  by  hi  nips  of  fccccs.  'Ilie  last  cause  (jf  intestinal 
obstruction  is  of  especial  interest  to  the  physician,  not  onlv  because 
it  occurs  comparatively  often,  but  still  more  because  it  is  readily 
diagnosed  and  easily  remoA'ed.  The  main  thing  is  that  lumps  of 
solid  fseces  accumulate  almost  exclusively  in  the  lower  portion 
of  the  colon  and  in  the  rectum,  being  thus  very  easily  accessible 
to  the  finger  introduced  into  the  anus.  Since  the  obstruction  is 
below,  therefore  the  whole  alxlomen  becomes  distended  in  this 
form  of  intestinal  obstruction,  and,  the  peritonetmi  not  being  in- 
volved, the  vomiting  is  not  so  obstinate  as,  for  instance,  during 
intussusception,  and  the  evidences  of  collapse  (feeble  pulse,  sunk- 
en face,  etc.)  set  in  comparatively  late. 

The  other  form  of  intestinal  obstruction,  being  very  charac- 
teristic and  thus  in  the  majority  of  cases  easily  diagnosticated, 
depends  upon  the  fact  that  one  portion  of  /ntestine  is  pushed  into 
the  neighboring  one  that  lies  next  below — intussusceptio.  s.  in- 
vaginatio. 

Depending  upon  the  place  of  formation  of  the  intussusception, 
the  pathologists  distinguish  invaginatio  ileo-ccecalem,  iliacam, 
colicam  and  ileo-colicam,  but  since  these  forms  are  seldom  to  be 
differentiated  at  the  bed-side,  such  classification  is  not  very  im- 
portant for  the  clinician.  It  is  sufficient  to  say  that,  usually,  we 
have  to  deal  with  invagination  of  the  small  bowels  into  the  colon 
(invaginatio  ileo-coecalis  and  ileo-colica). 

This  malady  most  often  occurs  in  children  (hirini^  the  lirst 
year  of  life.  The  process  of  the  invagination  makes  itself  evident 
mostly  by  the  sudden  abdominal  pain,  persistent  z'oniitiug  and  con- 
stipation. The  vomitus  consists  first  of  remains  of  food,  then 
simply  of  mucous  fluid  mixed  with  bile,  or  sometimes  with  ffeces. 
However,  in  children  there  rarely  occurs  f?ecal  vomiting,  because 
they  do  not  survive  to  that  event.  Especially  characteristic  of  in- 
vagination is  the  occurrence  during  the  first  twenty-four  hours 
(in  adults  later)  of  frequent,  bloody-mucous  dejections,  or  of  pure 
blood,  associated  with  tenesmus  of  the  rectum.  The  tenesmus  is 
the  stronger  and  the  bloody  stools  are  the  more  frequent,  the 
lower  in  the  intestinal  tract  the  invaginated  portion  occurs.  The 
small  admixture  of  f?eces  at  the  beginning  does  not  diminish  at 
all  the  importance  of  this  symptom,  because  faeces  may  be  present 
in  the  portions  of  the  bowels  below  the  invagination,  and  besides 


198  OBSTINATE    CONSTIPATION     AND     VOMITING 

there  does  not  always  occur  at  once  a  complete  occlusion  of  the 
lumen  of  the  bowels  at  the  moment  the  invagination  takes  place, 
but  only  later  on,  when  the  strangulation  of  the  inpacted  portion 
produces  an  inflammatory  swelling  of  its  layers,  especially  of  the 
peritoneal  covering  and  the  mucous  membrane. 

On  the  other  hand,  one  should  bear  well  in  mind  that  if  the 
colon  is  not  involved  in  the  process  of  invagination  ( invaginatio 
iliaca),  then  bloody  dejections  may  be  absent,  so  that  their  absence 
does  not  exclude  invagination,  especially  in  case  another  pathog- 
nomonic symptom  of  this  lesion  exists,  namely,  if  one  succeeds  in 
feeling  through  the  abdominal  walls,  in  some  part  of  the  abdomen, 
a  sausage-like  tumor  with  a  smooth  surface  which  is  slightly 
movable.  The  size  of  the  tumor  depends  upon  the  degree  of  in- 
paction  which  produces  the  tumor.  Unfortunately  this  symptom 
is  frequently  absent,  and,  if  present,  then  only  in  the  beginning, 
because  later  on  it  is  masked  by  the  considerable  tension  of  the 
abdominal  walls  due  to  meteorism;  the  latter  necessarily  occurs 
during  the  intestinal  obstruction,  increasing  with  each  day.  Tn 
this  period  the  inpacted  portion  of  the  bowels  may  be  felt  only 
in  case  it  sinks  down  to  the  rectum.  The  finger  introduced  in 
the  rectum  feels  as  if  it  touches  the  uterine  neck,  which  may  be 
encircled. 

The  abdominal  pains  are  at  first  of  a  paroxysmal  character, 
but  later  on,  when  peritonitis  develops  at  the  point  of  the  invag- 
ination, ([uickly  spreading  over  the  neighboring  parts,  then  the 
abdominal  ])ains  become  constant,  increasing  especially  upon  press- 
ure. Simultaneously  fever,  which  is  absent  at  the  beginning,  ap- 
pears ;  but  symptoms  of  collapse  in  the  form  of  pale,  sunken 
face,  thread-like  pulse,  coolness  of  the  extremities,  etc.,  set  in 
very  early. 

Fatal  termination  occurs  approximately  from  the  fourth  up 
to  the  tenth  day.  Convalescence  through  the  spontaneous  delivery 
of  the  invaginated  gut  during  the  first  days  of  the  disease,  or 
through  the  gangrenous  sloughing  oft"  of  the  constricted  portion 
after  many  weeks,  belongs  to  the  great  rarities. 

Thus,  invagination  dift'ers  from  other  forms  of  intestinal 
obstruction  by  the  presence  in  the  abdomen  of  a  sausage-like 
tumor  and  by  bloody  dejections  as  well.  It  is  true  that  a  like 
tumor   mav   also  be  observed   during-  stercoral   obstruction,   but 


0BSTIXAT1-:    rOXS'lIl'ATlON     AXO     VOMITIXG  lC)ij 

in  such  a  case,  as  well  as  when  the  invaginated  portion  cannot  be 
palpated,  the  diagnosis  ma}-  be  easily  based  on  the  presence  of 
the  bloody  stools.  At  any  rate,  to  confound  invagination  with 
intestinal  obstruction  due  to  the  accunndation  of  faeces  or,  in 
general,  to  foreign  bodies,  is  difficult,  because  invagination 
almost  exclusively  occurs  in  nurslings,  in  whom  obstruction  of 
the  bowels  by  faeces,  etc.,  almost  never  happens. 

Invagination  might  be  mistaken  for  a  common  dysenterx  be- 
cause of  violent  tenesmus  and  frequent  bloody  dejections.  But 
dysentery  never  starts  with  sudden  abdominal  pain,  neither  is  it 
accompanied  by  persistent  zviuiting;  meteorism  is  here  also  ab- 
sent, on  the  contrary  the  ahdonien  is  sniikcii. 

If  invagination  of  the  intestines  gives  rise  to  peritonitis, 
then  it  is  easy  to  recognize  this  complication  from  the  violent 
pain  fulness  of  the  abdomen  on  pressure,  but  it  is  not  always  easy 
to  say  what  an  existing  peritonitis  has  developed  from.  If  the 
physician  did  not  see  the  onset  of  the  disease,  then  there  remains 
onl_\  the  circumstantial  history.  One  may  usually  learn  that 
symptoms  of  invagination  existed  several  days  before  the  occur- 
rence of  painfulness  of  the  abdomen. 

Prolapsus  ani  can  hardly  ever  be  confused  with  the  protrusion 
per  anum  of  the  invaginated  gut,  because  in  the  former  case  the 
finger  introduced  between  the  margin  of  the  anus  and  the  pro- 
truded portion  of  the  rectum  very  soon  meets  an  obstacle  pre- 
sented by  the  flexure  of  the  intestinal  wall. 

According  to  English*  symptoms  of  intestinal  obstruction 
may  depend  upon  distension  of  the  bladder.  His  observations 
show  that  the  pelves  of  children,  being  narrow,  an  insignificant 
overfilling  of  the  bladder  suffices  for  a  complete  compression  of 
the  rectum,  and  thus  for  the  occurrence  of  symptoms  of  intestinal 
obstruction.  He  proves  this  opinion  by  two  cases  (one  post- 
mortem), on  the  ground  of  which  he  claims  that  some  cases  of 
ileus  in  children  have  been  but  those  of  retention  of  urine. 

[Pyloric  stenosis.  Persistent  vomiting  and  constipation  in 
children  may  also  be  due  to  stenosis  of  the  pylorus,  which  disease 
was  first  fully  described  in  America  by  Meltzer,  in  1898,  similar 
communications  having  previously  appeared  in  derman  medical 
literature.    This  disease  is  characterized  : 

*.rahrb.  fiir  Kiudcrh.     VIII.     S.  yg. 


200  OI'.STINATE    CONSTIPATION     AND    VOMITING 

(i)  Bx  z'ouiiting  occurring  even  after  small  quantities  of 
food. 

(2)  By  visible  peristaltic  iiwz'cineiits  of  the  stouiach. 

(3)  By  feeling  a  cylindrical  and  movable  tumor  in  the  py- 
loric region  of  the  stomach. 

(4)  By  secondary  dilatation  (not  a  constant  symptom)  of 
the  stomach. 

(5)  The  constant  absence  of  bile  in  the  vomited  masses. 

(6)  Persistent  constipation  accompanied  by  diminution  of 
the  quantity  of  the  urine ;  depressed  alxlomen  and  distended  epi- 
gastrium. 

The  latter  s}mptoms,  in  connection  with  those  under  (2)  and 
(3),  render  the  diagnosis  certain. 

The  pathologico-anatomical  characteristics  of  this  disease,  ac- 
cording to  some  authors  ( Thompson,  I'faundler)  is  a  functional 
spasm  of  the  jjylorus,  so  that  the  treatment,  according  to  this  view, 
should  be  medical;  in  the  opinion  of  others  (Meltzer)  the  hyper- 
trophy of  the  muscles  is  associated  with  the  presence  of  dense 
fibrous  tissue  in  the  submucosa,  so  that  the  treatment  should  be 
surgical.*  l^'urther  observations  have  indicated  the  latter  view  to 
be  more  correct  and  operation  (pyloroplasty)  has  been  very  suc- 
cessfully ])erformed,  among  others  by  Cautley  and  Clinton 
Dent.=^* 

How  little  familiar  many  physicians,  even  of  great  experience, 
are  with  this  condition,  is  shown  by  the  following  case  of  P.  Da- 
vidson, described  b\-  him  in  No.  44  of  The  Liverpool  Medico-Chi- 
rurgical  Journal.  kjo3.'''*'^'' 

"R.  T.  S.,  a  full-time,  well-developed  male  child,  bon:  July, 
1901.  He  was  suckled  for  a  few  days,  and  afterwards,  owing  to 
failure  of  the  mother's  milk,  was  fed  with  cow's  milk  diluted. 
From  birth  he  suffered  from  disinclination  to  suck,  flatulence,, 
vomiting.  \'arious  artificial  mfants'  foods  were  tried,  and  finally 
a  wet-nurse,  but  all  without  benefit.  \'omiting  and  wasting  con- 
tinued. The  vomiting  was  of  a  very  violent  character,  so  that  the 
contents  of  the  stomach  were  ejected  some  distance,  the  child  be- 

*Cheinisse :  La  Sciiiaiiic  ^h^dicalc,  1903,  pp.  261-263. 
**Lancct,  December,  20,  1902. 

***Congenital  Hypertrophy  of  Pylorus.     By  P.  Davidson,  Senior  Physi- 
cian, Infirmary  for  Children,  Liverpool. 


APPEXDKITIS    AND    PEUITVPHLITIS  20I 

coming  livid  in  the  face  during  the  act,  and  greatly  exhausted 
after  it  was  completed.  It  appeared  to  the  parents  that  the  quan- 
tity ejected  was  more  than  the  child  could  have  taken  in  its 
feedings. 

When  I  saw  the  child  on  .Vugust  27th  it  was  about  six  weeks 
old.  It  was  languid  and  wasted.  There  was  evidence  of  great 
dilatation  of  the  stomach ;  the  lower  part  of  the  abdomen  was 
empty  and  contracted.  Washing  out  the  stomach  was  attempted, 
with  the  result  of  setting  up  this  violent  act  of  vomiting  of  the 
character  described  above.  The  existence  of  a  congenital  obstruc- 
tion at  the  lower  end  of  the  stomach  was  evident,  and  on  the  fol- 
lowing visit  I  asked  Mr.  ^Murray  to  see  the  child,  in  view  of  its 
being  relieved  by  an  operation.  During  our  examination  marked 
peristaltic  contractions  of  the  walls  of  the  stomach  were  visible 
under  the  skm.  It  was  our  opinion  that  the  child  was  too  enfee- 
bled to  stand  the  shock  of  abdominal  section. 

Rectal  feeding  was  suggested. 

The  child  died  of  inanition  and  exhaustion  on  September  4th. 

A  post-mortem  examination  was  made.  The  stomach  was 
enormously  dilated;  the  pyloric  end  firmly  contracted,  and  feeling 
like  a  solid  tube.  The  intestines  were  contracted  and  almost 
empty.  I  have  no  recollection  of  seeing  a  similar  case  to  this  one. 
The  symptoms  were  quite  distinct  from  those  of  ordinar}-  infantile 
dyspepsia  and  atrophy,  and  could  not  fail  to  attract  attention  to 
the  existence  of  a  congenital  obstructive  lesion. 

The  microscopic  examination  showed  that  the  stenosis  de- 
pended on  an  enormous  hypertrophy  of  the  muscular  coat,  the 
pyloric  sphincter ;  the  mucous  membrane  in  the  vicinity  being 
normal." — Earle.  ] 

Persistent  vomiting  and  constipation,  with  abdominal  pains, 
meteorism  and  collapse,  are  also  met  with  during  appendicitis  and 
peritonitis. 

APPENDICITIS  AND  PERITYPHLITIS. 

Iiiflaiiuitatioii  of  the  verniifonn  process  and  of  the  abdominal  cov- 
erings of  the  ccrcnni. 
This  disease  very  seldom  occurs  in  nurslings,  usually  being 
observed  in  children  from  five  up  to  ten  years  of  age  who  are 
inclined  to  constipation.     Although  this  disease  begins  with  ab- 


202  APPENDICITIS    AND    PERITVPIILrriS 

■dominal  pain,  yet  never  so  suddenly,  during  the  complete  health, 
as  happens  in  invagination.  On  the  contrary  there  are  precursors 
in  the  form  of  disorders  of  digestion,  of  temporary,  coUc-like  ab- 
dominal pains,  loss  of  appetite  and  constipation.  The  best  grounds 
for  the  diagnosis  belong  to  the  location  and  the  character  of  the 
pain. 

Painfulness  appears  first  of  all  in  the  region  of  the  ccFCum. 
Palpation  readily  shows  that  the  point  of  severest  pain  corresponds 
to  the  position  of  the  appendix,  the  so-called  McBurney's  point, 
that  is,  near  the  center  of  a  line  connecting  the  navel  with  the 
anterior  superior  iliac  spine.  The  pain  increases  upon  pressure 
Simultaneously  with  the  pain,  or  soon  after,  a  violent  tension 
of  the  abdominal  wall  appears,  [and  hyperiesthesia  of  the  skin  of 
the  abdominal  wall  at  the  point  corresponding  to  the  appendix ;  a 
slight  pinching  of  the  skin  causes  extreme  pain  if  done  over  the 
point  of  the  appendix  (Dieulafoy).]  Likewise  at  the  same  time 
we  find  fever  and  vomiting,  usually  repeated,  which  therefore 
later  becomes  bilious  and  even  fjecal ;  the  constipation  which  had 
been  existing  before  is  persistent.  On  the  second  or  third  day 
a  circumscribed  hardening  in  the  form  of  an  immovable  tionor, 
very  painful  up0)i  pressure,  may  be  felt  in  the  right  iliac  region 
at  a  point  which  exactly  corresjxmds  to  the  ciecum. 

The  disease  ends  either  by  gradual  resolution,  all  symptoms 
abating,  or  it  gives  rise  to  the  development  of  general  peritonitis, 
usually  fatal,  or,  finally,  the  process  ends  with  the  formation  of 
an  abscess  in  the  region  of  the  caecum. 

[Resides  the  symptoms  of  appendicitis  enumerated  there  is 
one  more  very  important  objective  sign  called  in  France  the  sign 
of  Hayem,  and  in  Germany  sign  of  Curschman.  This  sign  refers 
to  the  blood-count  in  appendicitis  being  based  on  Hayem's  investi- 
gations of  1889*  that  circumscribed  suppurations  following  acute 
inflammatory  processes  are  invariably  accompanied  by  leucocytosis. 
This  law  was  established  by  Curschman  m  regard  to  appendicitis 
in  the  year  1901,**  namely  that  appendicitis  is  accompanied  by 
the  increase  of  the  number  of  leucocytes.  Da  Costa,  in  America, 
published  his  observations  on  the  same  subject  in  118  cases  of  ap- 


*G.  Hayem :  Du  sang  et  de  ses  alterations  anatomiques.     Paris.   1889. 
**Miinch.  Med.  Wocli.  1901,  pp.  1907  and  1962  (March  and  December). 


APPENDICITIS    AXD    PERITVP 11  LITIS  2O3 

pendicitis,  in  the  same  year  as  Curschman,  and  came  to  the 
same  conclusions.  Soon  afterwards  there  appeared  numerous 
investigations  along  the  same  line  in  France,  Germany,  America, 
etc.,  with  results  as  follows : 

(i)  Generally  one  may  admit  leucocytosis  if  there  is  more 
than  10,000  white  corpuscles  in  one    cub.  milimeter. 

(2)  In  the  beginning  of  appendicitis  there  is  a  slight  leu- 
cocytosis (11,000 — 15,000)  even  in  the  absence  of  any  suppura- 
tion. 

(3)  The  number  of  leucocytes  increases  with  the  appear- 
ance of  the  first  signs  of  irritation  of  the  peritoneum. 

(4)  The  number  of  leucocytes  not  exceeding  25,000  indi- 
cates a  mild  form  of  appendicitis,  which  may  end  spontaneously 
with  resolution ;  but  such  a  number  being  permanent  denotes  a 
suppuration,  and  thus  that  operation  should  be  performed  with- 
out delay. 

(5  )  Absence  of  leucocytosis  does  not  prove  that  a  given  case 
is  not  appendicitis,  being  often  absent  (a)  when  the  inflammation 
of  the  peritoneum  becomes  diffuse  (diffuse  peritonitis),  so  that 
the  defensive  force  of  the  organism  is  too  weak  to  produce  leu- 
cocytosis, and  (b)  when  the  abscess  is  encapsulated. 

(6)  The  qualitative  count  of  the  leucocytes  is  of  still  more 
importance  than  a  quantitative  count,  because  an  increase  in  the 
pohmorphonuclear  cells  out  of  proportion  to  the  other  elements 
is  indicative  of  progression  (Longridge). 

(7)  The  blood  count  in  appendicitis  requires  the  most  rigor- 
ous technique  (Deaver),  and  to  avoid  errors  it  must  be  per- 
formed several  times  a  day,  and  each  time  new  portions  of  blood 
should  be  taken. 

(8)  The  "curvature"  of  leucoc}tes  in  appendicitis  is  a 
symptom  of  far  greater  importance  than  the  pulse  and  tempera- 
ture.— Earle.] 

All  these  symptoms  are  plainly  sufticient  for  the  correct  diag- 
nosis. 

From  invagination,  appendicitis  and  perityphlitis  dift'er  by 
the  absence  of  bloody  stools,  by  the  character  of  the  pain  (from  the 
very  first  of  the  disease  the  pain  is  of  inflammatory  nature,  i.  e., 


*Am.  Jour,  of  Med.  Sc,  Novemb.,  1901. 


204  APPENDICITIS    AND    PERITYPHLITIS 

increases  upon  pressure),  and  by  the  fever.  Regarding?  the  con- 
stipation, this  symptom  is  not  a  constant  one  in  perityphhtis,  be- 
cause (harrhcea  sometimes  occurs.  A  very  important  differential 
sign  may  be  obtained  from  the  digital  examination  per  rectum ; 
in  perityphhtis  it  is  possible  to  sometimes  feel  resistance  in  the- 
right  iliac  region  in  a  direction  toward  the  horizontal  branch  of 
the  pubic  lx>ne  (Karewsky). 

[Rectal  examination  is  of  especial  value  when  the  appendix 
is  located  in  the  pelvis   (Lockwood).* — Earle. ] 

Appendicitis  occurs  in  a  very  mild  form,  as  well  as  in  a  severe 
one.  In  the  former  case  there  will  be  acute  pain  in  the  caecaL 
region,  vomiting,  and  there  may  also  be  fever,  all  these  symptoms 
disappearing  very  soon,  that  is,  after  twelve  or  thirty-six  hours. 
This  is  the  so-called  appendicular  colic.  But  there  are  also  cases 
in  which  acute  fatal  peritonitis  follows  because  of  early  perfora- 
tion of  the  vermiform  process,  death  (xx'urring  then  in  from  three 
to  six  (la}s. 

( )f  an  cntirclv  different  form  arc  cases  of  chronic  appendi- 
citis, characterized  by  fre(|ucnt  relapses.  The  clinical  picture 
differs.  In  one  case  the  patient  constantly  complains  of  dull 
pain  in  the  right  iliac  region,  the  pain  increasing  during  walking 
or  physical  exercise  in  general,  but  palpation  does  not  reveal  any- 
thing abnormal.  In  other  cases  the  first  attack  of  inflammation 
terminates  in  apparent  complete  recovery,  but  after  a  few  weeks 
or  months  the  second  seizure  suddenly  appears,  then  the  third, 
and  so  on.  It  frequently  happens  that  the  second  or  third  attack  is- 
much  severer  than  the  first,  and  kills  the  patient. 

For  the  differential  diagnosis  of  perityphlitis  one  should 
also  bear  in  mind  typhlitis  stercoralis  (inflammation  of  the 
caecum),  when  accumulation  of  faeces  in  the  caecum  also  gives  rise 
to  an  oval  tumor  in  this  region,  to  abdominal  pains,  vomiting, 
meteorism,  constipation  and  fever,  with  the  difference  that  the 
peritoneum  not  yet  being  involved  (otherwise  it  would  be  peri- 
typhlitis), the  pain  upon  pressure  is  not  great.  It  is  further  char- 
acteristic that  after  a  copious  stool  due  to  a  laxative  or  enema, 
rapid  abatement  of  all  symptoms  follows.  However,  it  is  impos- 
sible to  make  sharp  boundaries  between  typhlitis  and  perityphlitis^ 


*Lancct:  Dec.  13.  1902 


APPENDICITIS    AND    PKRITVPII  LITIS  20^ 

there  being  reason  why  some  authors,  as,  for  instance,  Jiiarthez 
and  Sanne*  hold  them  to  be  different  grades  of  one  and  the  same 
•disease. 

[Many  authors  entirely  deny  the  existence  of  so-called  typh- 
litis stercoralis  (inflammation  of  the  caecum  due  to  f?ecal  obstruc- 
tion). Especially  has  Dieulafoy  (France)  insisted  in  numerous 
papers,  in  clinical  lectures,  and  in  his  well-known  Text-Book  of  In- 
ternal FatJwlogy,  that  "The  old-time  typhlitis  by  frecal  obstruc- 
tion (t.  stercoralis)  with  perityphlitis,  ulceration,  peritonitis,  etc., 
should  be  omitted,  for  this  is  never  primary ;  but  when  it  does  oc- 
cur, and  this  is  very  seldom,  it  is  invariably  consecutive  to  ap- 
pendicitis." Simple,  catarrhal,  mucous  and  other  types  of  typhilitis 
and  coli-typhlitis  are  called  by  Dieulafoy  'pseudo-typhlitis,'  but 
typhlitis  stercoralis,  i.  e.,  due  to  faecal  stagnation,  as  described  by 
•older  writers,  does  not  exist."** — Earle.] 

During  inflammation  of  the  psoas  muscles  (psoitis)  there  is 
also  some  pain  fulness  upon  pressure  and  an  immovable  tumor 
in  the  region  of  the  iliac  fossa,  associated  with  fever,  but  besides 
the  symptoms  on  the  part  of  the  stomach  and  peritoneum  being 
absent  ( absence  of  vomiting  and  pain  upon  pressure  over  the  ab- 
domen, excluding  only  a  circumscribed  area  corresponding  to 
liardening),  the  diagnosis  also  rests  on  the  position  occupied  by 
the  tumor :  the  latter  is  palpated,  during  psoitis,  in  the  iliac  fossa, 
frequently  spreading  over  the  upper  third  of  the  inner  surface  of 
the  femur  (the  region  of  the  trochanter  minor),  while  in  peri- 
typhlitis it  occupies  the  region  of  the  caecum,  that  is,  somewhat 
higher  and  more  externally.  The  femur  always  remains,  during 
psoitis,  immobile  on  the  diseased  side,  this  symptom  being  ob- 
served in  aft'ection  of  the  caecum  only  when  the  inflammation 
spreads  to  the  cellular  tissue,  which  lies  on  the  posterior  surface 
■of  the  caecum — paratyphlitis. 

[In  the  differential  diagnosis  of  appendicitis  one  should 
have  thought  of  the  following  diseases  (children's  diseases)  : 

( 1 )  Movable  kidney. 

(2)  Hepatic  colics. 

(3)  Empyema  of  the  gall  bladder. 


*Traite  clinique  et  pratique  des  maldies  d'enf.     Vol.  II.,  p.  473. 
**Tlic  Medical  Week  (English  Edition  of  La  Scmaine  Medicate,  il 
pp.   126,  137,  etc.). 


205  APPENDICITIS    AND    PERITVPII  LITIS 

(4)  Acute  phlegmonous  cholecystitis  and  gangrene  of  the 
gall-bladder. 

(5)  Nephritic  colic 

(6)  Typhoid  fever. 

(7)  Lead-colics. 

(8)  Diffuse  enteritis  (entero-typhlo-colitis) . 

From  movable  kidney  appendicitis  differs  by  the  character 
of  the  pain  and  its  location :  it  is  not  so  severe  upon  pressure  as 
in  appendicitis,  corresponding  to  the  anatomical  position  of  the 
kidney ;  the  tension  of  the  muscles  is  almost  absent  or  far  less 
pronounced  than  in  appendicitis ;  there  is  no  elevation  of  tempera- 
ture and  no  acceleration  of  pulse.  While  very  characteristic  of 
movable  kidney  v^e  have  prolonged  and  persistent  nausea. 

It  is  much  more  difficult  to  dift'erentiate  appendicitis  from  he- 
patic colic,  as  both  may  have  a  sudden  onset  marked  by  severe  pain 
and  vomiting.  Aside  from  the  history  the  character  of  the  pain 
may  serve  us  in  the  dift'erential  diagnosis,  it  being  more  persistent 
and  severe  in  hepatic  colic  than  in  appendicitis,  and  is  confined 
more  to  the  inferior  portion  of  the  right  chest,  near  the  point  of 
the  cartilage  of  the  ninth  rib;  while  in  appendicitis  the  pain 
is  situated  in  the  right  iliac  fossa. 

In  empyema  of  the  gall-bladder  the  sac  is  distended  and  fol- 
lows the  respiratory  movements  of  the  patient,  especially  when  he 
is  standing,  and  there  are  no  adhesions.  The  history  of  the  case 
and  the  tension  of  the  superior  portion  of  the  right  rectus  abdom- 
inis muscle  is  characteristic  of  rupture  of  the  empyema  of  the 
gall-bladder,  thus  differing  from  an  appendicular  abscess. 

In  acute  phlegmonous  cholecystitis  and  gangrene  of  the  gall- 
bladder the  vomiting  is  more  obstinate  than  in  appendicitis ;  the 
pain  is  very  severe  in  the  event  of  affection  of  the  biliary  ducts, 
radiating  toward  the  scapular  region  and  becoming  general;  the 
respiration  is  frequent,  and  of  the  costal  type;  general  physical 
depression  is  very  great  and  general  peritonitis  sets  in  very  rap- 
idly (Deaver).* 

Nephritic  colic  dift'ers  from  appendicitis  by  the  pain  being 
confined  to  the  hmibar  region,  decreasing  upon  pressure  and  ra- 
diating along  the  ureter ;  the  pain  also  decreasing  after  micturi- 


*J.  B.  Deaver:  Annals  of  Surgery,  March  189S. 


APPENDICITIS    AND    PERITVPII  LITIS  207 

tion ;  here  the  tension  of  ahdoniinal  muscles  is  absent,  as  well  as 
the  oedematous  condition  of  the  right  iliac  region  ;  aside  from  this 
the  urine  may  give  valuable  points  regarding  the  diagnosis. 

The  differential  diagnosis  between  typhoid  fever  and  appendi- 
citis is  sometimes  very  difficult.  When  the  history  of  the  disease 
is  insufficient  and  the  usual  methods  of  diagnosing  typhoid  fail, 
then  blood  count  may  be  of  very  distinct  aid.  As  already  pointed 
out,  appendicitis  is  accompanied  in  the  majority  of  instances  by 
leucocytosis,  while  not  so  in  typhoid. 

Lead-poisoning  may  closely  resemble  appendicitis,  as  shown 
by  the  observations  of  Apert,  Mathieu,  Tribulet  and  other  writ- 
ers.* In  the  dififerential  diagnosis  we  must  take  into  consideration : 
(i)  The  history;  (2)  The  characteristic  line  on  the  gums;  and 
(3)    Absence  of  fever. 

Then  again  it  is  very  important  to  distinguish  between  ap- 
pendicitis and  diffuse  catarrh  of  the  whole  intestinal  tract  (entero- 
typhlo-colitis).  According  to  Dieulafoy  the  pain  in  the  latter  dis- 
ease is  only  exceptionally  located  in  the  right  iliac  fossa,  the  whole 
abdomen  commonly  becoming  painful ;  therefore,  when  asked 
about  the  situation  of  the  pain  the  patient  points  to  the  region 
of  the  transverse  and  descending  colon.  Further,  the  muscular 
tension  (contracture)  and  the  hyper?esthesia  of  the  skin  covering 
the  lower  abdomen  is  never  so  pronounced  in  entero-typhlo-colitis 
as  in  appendicitis.  And  then  the  history  will  always  show  that 
the  patient  suffering  with  entero-typhlo-colitis  had  complained  for 
a  long  time  of  different  gastro-intestinal  disorders^''* 

Further  neuromata  in  the  right  iliac  fossa  may  give  rise  to 
severe  attacks  of  pain,  but  a  careful  examination  of  the  region 
and  its  palpation  will  almost  always  bring  out  these  tumors,  and 
thus  settle  the  diagnosis. 

It  scarcely  comes  within  the  province  of  the  pediatrist  to 
determine  between  appendicitis  and  different  affections  of  the 
pelvic  organs  (womb,  ovaries,  Fallopian  tubes,  etc.)  and  wc  there- 
fore refrain  from  entering  upon  the  cjuestion. 

Finally,  it  should  not  be  forgotten  that  very  often  the  clinical 


*See  Discussions  in  Soc.  Med.  des  Hopitaux  (Paris),  Feb.  27.  1903,  in 
La  Semaine  Med.,  1903. 

**La  Semaine  Medicalc,  1899,  p.  68. 


2o8  APPENDICITIS    AND    PERITYPHLITIS 

expression  of  appendicitis  is  nothing  more  than  a  reflex  from  the 
chest,  i.  e.,  appendicitis  is  simulated  by  some  affections  of  the 
lungs  or  pleura.  Such  very  instructive  cases  have  been  lately  re- 
ported liy  H.  L.  Barnard,  J.  P.  Crozer  Griffith  and  J.  B.  Herrick. 
The  differential  diagnostic  points  in  these  cases  are,  according  to 
Griffith,  the  following : 

(i)  The  sudden  rise  of  temperature  to  103  degrees  F.  or 
thereabouts,  and  a  tendency  to  maintain  this  degree. 

(2)  The  acceleration  of  respiration,  which  is  out  of  pro- 
portion to  the  pulse  rate  or  to  the  pyrexia. 

(3)  The  relaxation  of  the  abdominal  walls  between  respira- 
tions. 

(4)  The  diminution  or  the  disappearance  of  tenderness  on 
deep  pressure  with  the  flat  of  the  hand. 

(5)  The  possible  presence  of  cough.* 

All  these  points  will  assist  in  most  cases  in  determining  the 
true  nature  of  the  disease  pneumonia. — Earle.] 

[Nevertheless  appendicular  attacks  which  very  frequently  af- 
fect children  otherwise  in  perfect  health,  are  almost  always,  says 
Ochsner  in  his  well-known  Clinical  Surgery,  looked  upon  by  the 
parents  and  friends,  and  frequently -fey  the  physician,  as  a  case  of 
violent,  acute  gastritis  or  enteritis,  resulting  from  some  indiscre- 
tion in  eating.  "This  is  so  common  that  one  rarely  sees  these 
young  appendicitis  patients  in  whom  the  correct  diagnosis  was 
made  from  the  beginning  of  the  attack.  Therefore,  the  most  im- 
portant point  is  in  dispelling  the  idea  that  a  severe  pain  in  the  re- 
gion of  the  stomach  in  children  coming  on  after  taking  indigestible 
food  is  due  to  gastritis  and  is  consequently  of  little  importance, 
because  so  often  a  careful  examination  will  demonstrate  this  con- 
dition to  be  a  gangrenous  or  perforative  appendicitis.  This  con- 
dition frequently  occurs  in  children  not  more  than  four  years  of 
age.  I  have  seen  a  number  of  cases  much  younger,  one  as  young 
as  seven  months,  and  the  accompanying  history  of  a  case  observed 
by  Dr.  W.  B.  Helm,  of  Rockford,  Illinois,  which  I  quote  because 
of  its  unusual  interest,  shows  that  it  ma}-  occur  in  those  still 
younger. 


*Pneumonia   and   Pleurisy   in   Early  Life   Simulating   Appendicitis,   by 
S.  P.  Crozer  Griffith  {J own.  Am.  Med.  Assoc,  Aug.  29,  1903,  No.  9). 


AITENDICITIS    AND    I'EKllA- 1' 1 1  1 ,1  I  h 


209 


This  i)atient,  a  bo}^  three  months  old,  was  seen  b}-  Dr.  Hchii, 
Jaiiuar\-  5.  1902.  He  had  suffered  ahnost  constantly  since  birth, 
crying"  much  of  the  time,  night  and  day.  Frequent  tenesmus,  al- 
though bowels  w^ere  easily  regulated.  The  mother's  milk  did  not 
agree  and  various  prepared  foods  were  tried.  The  child  took 
food  ravenously,  but  never  seemed  satisfied.  There  was  no  gain 
in  weight  and  some  fever  persisted  most  of  the  time.  When  the 
child  was  five  weeks  of  age  the  local  physician  was  called  and  de- 
tected a  right  oblique  inguinal  hernia.  There  was  apparently  no 
trouble  in  reducing  it  and  he  tried  various  forms  of  retentive  ap- 
paratus. Still  the  crying,  straining  and  fever  continued.  Seven 
weeks  later  the  patient  began  to  fail  rapidly,  and  Dr.  Helm  found 
it  with  a  temperature  of  103'^  F.  and  pulse  varying  from  160  to 
190.  The  child  weighed  only  eight  pounds  and  still  cried  most 
of  the  time.  There  was  a  hernial  protrusion  the  size  of  a  small 
hen's  egg.  The  bulk  of  the  mass  could  be  readily  returned,  but  a 
small  object  in  the  inguinal  canal  remained.  It  seemed  like  an 
undescended  testicle,  but  both  of  these  organs  were  found  to  be 
in  the  scrotum.  Repeated  trials  failed  to  return  it  to  the  abdo- 
men, so  an  operation  was  advised.  On  opening  the  canal  the 
■doctor  found  that  the  reducible  portion  was  the  head  of  the  colon, 
and  the  irreducible  part  was  the  appendix,  slightly  adherent  and 
greatly  congested.  He  removed  the  appendix  and  closed  the 
canal  by  the  Bassini  method.  The  pain  was  apparently  lessened 
at  once, the  fever  disappeared  on  the  third  day  and  the  child  gained 
two  pounds  during  the  first  ten  days  and  has  since  made  an  unin- 
terrupted recovery."* — Earle.] 

Acute  inflammation  of  the  peritoneum — PERrroNiTcs 
ACUTA,  is  indicated  by  such  well-defined  symptoms  that  it  is  easily 
■diagnosed.  The  most  characteristic  symptom  is  severe  pain  in  the 
entire  abdomen,  increasing  upon  the  slightest  pressure,  as  well  as 
■during  movement,  cough  and  other  conditions  associated  with  the 
action  of  the  abdominal  muscles,  so  that  the  patient,  even  against 
his  will,  lies  immovable  on  his  back  with  the  legs  slightly  bent  and 
literally  does  not  allow  anything  to  touch  his  abdomen.  Along 
with  the  pain  there  is  fever  (about 40 degrees  C. — 104  degrees  P.), 
persistent  vomiting  and   constipation,   the  abdomen   being   very 

*Ochsner:  Clinical  Surgery,  1903.  pp.  126-128. 


2IO  APPENDICITIS    AND    PERITYPHLITIS 

much  distended  (especially  is  the  diaphragm  elevated)  with  ten- 
sion of  the  abdominal  walls. 

Under  the  influence  of  irritation  of  the  peritoneum  and  fre- 
quent vomiting  collapse  rapidly  develops  (thread-like  pulse,  sunk- 
en face,  coldness  of  the  extremities). 

Great  similarity  to  peritonitis  may  be  presented  by  gymnastic 
pains  in  the  abdominal  muscles.  When  children  start  g-ymnastic 
exercising  they  often  complain,  during  the  first  days,  of  abdominal 
pains  in  the  epigastrium  or  between  the  navel  and  sympliysis 
pubis.  The  examination  shows  that  this  pain  is  localized  in  the 
recti  muscles  of  the  abdomen,  being  indicated  by  increasing  upon 
pressure  and  some  movements  performed  by  the  straight  abdom- 
inal muscles.  Similar  ])ains  are  also  met  with  in  children  in 
whooping-cough  because  of  tension  of  the  muscles  during  cough. 

These  pains  being  mild  are  not  difficult  to  diagnose,  but  the 
question  is  altered  in  grave  cases.  The  pains  then  spread  all  over 
the  abdomen,  being  of  a  peritoneal  character,  that  is,  they  increase 
upon  the  slightest  pressure  and  compel  the  patient  to  maintain  an 
immovable  posture.  Together  with  the  pains  there  also  appear 
other  symptoms  of  peritonitis,  such  as  vomiting,  constipation, 
high  position  of  the  diaphragm  and  fever,  so  that  during  the  first 
day  of  the  disease  the  diagnosis  is  indeed  perplexing.  But  even 
then  there  are  some  differential  points  ;  first  of  all,  the  pulse  re- 
mains full,  not  very  much  quickened,  other  signs  of  collapse  being 
absent ;  second,  fever  does  not  rise  higher  than  38.5  degrees  C. 
(101.3  degrees  F.)  ;  third,  at  last  the  history  may  point  to  some 
overexertion  of  the  muscles.  In  one  of  my  cases,  described  in 
the  January  number  of  Mcdizinskoie  Oboarenie,  1880,  a  ten-year- 
old  boy  became  ill  with  the  symptoms  mentioned  after  he  had  ex- 
ercised in  various  ways  which  required  exertion  of  the  abdominal 
muscles,  especially  of  the  straight  ones. 

The  further  course  of  the  affection  will  solve  the  problem  be- 
cause gymnastic  myositis  is  very  soon  over  if  a  quiet  position  is^ 
maintained  by  the  patient ;  in  two,  or  at  least  three,  days  vomiting 
and  fever  disappear,  the  pains  become  concentrated  in  the  straight 
abdominal  muscles,  especially  in  their  lower  parts,  and  pass  en- 
tirelv  awav  toward  the  end  of  the  week. 


SEMEIOLOGY  OF  ABDOMINAL  PAIN. 

Abdominal  pain,  like  headache,  belongs  to  the  most  uncertain 
of  symptoms,  inasmuch  as  its  causes  may  be  very  manifold. 

In  this  section  I  will  speak  only  about  abdominal  pains  in 
older  children. 

In  treating-  a  child  complaining  of  abdominal  pain,  one  should 
first  of  all  decide  the  question  as  to  the  location  of  the  distress, 
that  is,  find  out  if  the  pain  is  localized  in  the  abdominal  wall,  or 
in  any  internal  organ. 

Pain  in  the  abdominal  wall  may  be : 

( 1 )  In  the  integument  of  the  abdomen. 

(2)  In  the  muscles  and  aponeuroses. 

(3)  In  the  peritoneum. 

I  shall  not  speak  of  uiflamiuatory  f>ain  of  the  skin  (erysipelas^ 
furunculosis,  etc.),  as  the  cause  of  pain  in  such  cases  is  clear. 

HyPER.ESTHESIA   of   the   SKIX    OF   THE   ABDOMEN. 

The  patient  complains  of  abdominal  pain  which  considerably 
increases  upon  any,  even  slight,  pressure  over  the  abdomen,  being 
thus  similar  to  the  pain  of  peritonitis.  Indeed  it  is  very  often 
mistaken  for  the  latter,  especially  when  appearing  during  a  dis- 
ease which  may  produce  peritonitis  as  a  complication,  for  in- 
stance, as  in  typhoid,  when  hypercesthesia  of  the  abdominal  skin 
belongs  to  the  most  common  symptoms.  It  is  not  difficult  to  avoid 
error,  the  diagnosis  resting,  first,  upon  the  signs  peculiar  of  hyper- 
sesthesia  of  the  skin  in  general,  and,  second,  on  the  absence  of 
other  symptoms  of  peritonitis. 

Hypersesthesia  of  the  skin  is  first  characterized  by  a  wide 
area  of  involvement.  In  typhoid  it  is,  for  instance,  readily  learned 
that  the  pain  is  not  limited  to  the  abdomen  alone,  but  extends  also 
over  the  thighs  and  the  chest  as  well ;  the  patient  equally  resists, 
by  the  features  of  the  -face  and  by  groaning,  to  pressure  over  the 
abdomen  as  well  as  upon  the  inner  surface  of  the  thighs.  Second, 
by  a  greater  pressure  causing  more  severe  pain  than  a  mild  one, 
while  the  pain   will  be  equally  severe  upon   pressing  either   the 


212  SEMEIOLOGV    OF    ABDOMINAL   PAIN 

abdominal  wall  itself,  or  only  the  folded  skin.  Third,  by  the  pain 
remaining  stationary  for  a  long  period,  in  typhoid,  for  instance, 
several  days  in  succession,  while  no  new  symptom,  peculiar  to 
peritonitis,  becomes  evident. 

Besides  in  typhoid  these  pains  due  to  hyperjesthesia  of  the 
skin  of  the  abdomen  and  other  parts  also  occur  in  meningitis 
(especially  cerebro-spinal  meningitis)  and  in  other  severe  febrile 
conditions,  as  well  as  in  general  nervousness,  particularly  in  girls 
during  the  period  of  puberty  (hysteria). 

Hypersesthesia  of  the  skin  in  typhoid,  when  well  developed, 
may  lead  the  physician  to  an  error  in  causing  him  to  suggest  men- 
ingitis when  the  latter  is  entirely  absent.  Such  a  mistake  hap- 
pened to  me  in  one  case  of  a  seven-year-old  girl,  entering  the 
hospital  on  the  fifth  day  of  the  disease  on  account  of  fever  of 
about  40.2  degrees  C.  (104.4  degrees  F.),  spleen-tumor,  uncon- 
sciousness and  contracture  of  the  neck.  The  general  hyperaesthesia 
of  the  abdominal  skin  was  so  pronounced  that  each  time,  upon 
folding  the  skin,  the  patient,  although  evidently  unconscious, 
would  scream.  In  view  of  this  symptom,  as  well  as  the  contracture 
of  the  neck  and  the  rapid  course,  a  diagnosis  of  cerebro-spinal 
meningitis  was  made  in  spite  of  the  speen  being  very  large  and 
painful,  the  pulse  accelerated  (152,  with  a  temperature  of  40.8 
degrees  C. — 105.5  degrees  F.)  and  absence  of  the  initial  vomiting. 
Death  occurred  on  the  ninth  day.  The  post-mortem  showed  a 
-recent  spleen  tumor  with  swelling  of  Fever's  patches  (in  ^hort, 
typhoid),  and  complete  absence  of  inflammatory  changes  in  the 
■cerebral  membranes). 

Pains  in  the  muscles  and  aponeuroses  of  the  abdomen 
arise  from  two  causes :  ( i )  From  catching  cold — rheumatism  of 
the  abdominal  muscles;  and  (2)     From  gymnastic  exercises. 

The  former  occurs  ver\-  seldom  and  from  my  own  experi- 
ence I  would  be  unable  to  say  anything.  Bamberger  points  out 
that  rheumatic  pains  of  the  abdominal  muscles  may  simulate 
peritonitis.  The  condition  probably  resembles  that  which  is  ob- 
served in  muscular  pains  due  to  gymnastic  exertions,  which  was 
mentioned  in  the  preceding  article  (page  210). 

Pain  in  the  peritoneum  during  inflammation  thereof  be- 
longs to  the  most  severe  suffering  related  to  the  abdomen.  It  is, 
jEirst,   indicated  by  its  constancy   (although   at  times  increasing, 


SEMEIOr.OCV    OF    AiiDoM  1  X  AL    I'AIN'  2I3 

colic-like,  under  the  intiucncc  of  the  peristaltic  movement  of  the 
intestines)  ;  second,  hv  increasing  upon  the  slightest  pressure  over 
the  abdomen ;  third,  by  always  being  accompanied  by  considerable 
tension  of  the  abdominal  walls;  and  fourth,  Ijy  being  associated 
with  other  symptoms  of  peritonitis,  namely,  vomiting,  constipation 
and  meteorism.  The  extension  of  the  pain  depends  upon  the  area 
of  the  inflammation ;  in  general  peritonitis  the  entire  abdomen 
is  painful,  in  the  circumscril)ed  variety  the  ]:)ain  is  limited  to  a 
correspondngly  small  space. 

In  childhood,  local  peritonitis  most  often  manifests  itself 
by  pains  in  the  CKcal  region :  Appendicitis  and  Perit_\phlitis  ( page 
201). 

In  chronic  peritonitis  the  pain  is  of  secondar}'  importance  and 
will,  therefore,  be  spoken  of  in  another  place  (section  on  the 
Enlargement  of  the  Abdomen). 

Pain  in  thf  bowels — ciifcralgia,  s.  colica,  is  characterized 
by  appearing  in  attacks  (paroxysms),  separated  by  free  intervals, 
tlw  pain  not  increasing  on  pressure  and  existing  ivithont  fever.  A 
mild  paroxysm  of  colic  does  not  produce  any  objective  signs  and 
may  be  recognized  only  from  the  patient's  complaints.  If,  how- 
ever, the  pain  be  grave,  then  the  patient  not  only  groans,  pain- 
fully distorting  his  face,  but  his  extremities  grow  cold,  perspira- 
tion covers  his  forehead,  the  j^ulse  is  small,  and  the  patient  is 
continuously  restless  ;  vomiting  often  appears. 

According  to  the  cause  and  the  case,  the  attack  lasts  from 
several  minutes  up  to  several  hours. 

Colics  may  depend  upon  either : 

(i)      Disease  of  the  intestines. 

(2)  Irritation  by  their  contents. 

(3)  Aft'ection  of  the  nerves  of  the  abdomen. 

(4)  Irritation  of  the  neighboring  organs. 

(i)  Colics  depending  npon  catarrh  of  the  small  bowels  are 
the  most  common.  The  attack  of  colicky  pain  usually  precedes 
a  diarrhoeal  dejection,  so  that  the  cause  of  the  pain  may  easily 
be  recognized.  If  the  colic  depends  upon  catarrh  of  the  large 
bowels,  or  dysentery,  then  it  occurs  much  oftener,  being  accom- 
panied by  tenesmus  of  the  rectum  and  a  mucous  stool.  Here 
may  also  be  included  colic  pain  associated  with  the  eliminalion 


214  SEMEIOLOGV    OF    ABDOMINAL    PAIN 

of  large  quantities  of  mucus  in  the  so-called  enteritis  pseudo-  meni- 
branacea. 

To  the  same  category,  that  is,  ])ain  due  to  disease  of  the 
bowels,  is  also  to  be  referred  violent  abdominal  pain  accompanying 
intestinal  obstruction,  for  instance,  intussusception  (page  197}, 
as  well  as  colics  sometimes  occurring  in  purpura  (see  Diseases  of 
the  Skin,  viz.,  cutaneous  haemorrhages)  and  probably  depending 
upon  hcemorrhages  into  the  intestinal  walls.  If  the  colicky  pains 
last  a  long  time,  being  associated  with  chronic  meteorism.  general 
wasting  and  paleness,  as  well  as  with  slight  fever,  then  it  points 
to  a  tubercular  peritonitis :  and  the  latter  becomes  certain  if  ten- 
sion of  the  abdominal  Dinscles  be  noted  together  with  various 
thickenings  that  may  be  felt  in  the  abdomen. 

(2)  To  the  second  group  are  referred  alxlominal  pains  due 
to  indii^cstible  food  {colica  ah  iiii^estis),  for  instance,  sour  fruits 
(the  history),  to  some  drugs,  accumulation  of  faeces  in  the  in- 
testines— colica  stcrcoralis  (constipation,  distension  of  the  abdo- 
men, sometimes  lumps  of  faeces  may  be  felt  through  the  abdominal 
wall.  The  pain  stops  quickly  after  removal  of  the  cause  by  means 
of  an  enema  or  laxative),  and  to  intestinal  wcjrms. 

Colic  due  to  worms  may  be  suspected  if  chronic  pains  in  a 
child  are  repeated  especially  in  the  mornings  on  an  empty  stomach, 
being  sometimes  accompanied  by  anaemia,  notwithstanding  the  ap- 
petite is  good,  the  stools  regular  and,  in  general,  symptoms  of  ca- 
tarrh of  the  stomach  and  intestines  completely  absent.  The  prob- 
ability becomes  still  greater  if  the  child  had  previously  eliminated 
ascarides  or  segments  of  a  tape-worm,  or  if  ova  of  the  latter  have 
been  detected  in  the  evacuations. 

Intestinal  worms  are  to  l>e  regarded  as  an  undoubted  cause 
of  abdominal  pains  onl}-  when  the  pain  entirely  disappears  after 
the  parasites  have  been  removed. 

(3)  Nen'ous  pain  in  flic  intestines  may  be  suspected  in  a 
case  where  we  cannot  find  the  cause  of  it  either  in  diseases  of  the 
bowels  (normal  stools,  good  appetite),  or  in  errors  of  diet  (the 
pains  do  not  increase  from  coarse  food,  neither  diminish  with 
the  best  diet),  or  in  intestinal  worms  (santonin  does  not  expel 
ascarides,  ova  of  tape-worms,  or  their  segments,  are  absent),  or 
in  the  irritation  of  neighboring  organs.  The  intensity  of  pain 
in  itself  is  here  of  little  help  in  the  diagnosis,  being  very  moderate 


s^;^IF.lnI/)G^•  oi'   aiidom  ix.\i.  paix  215 

and  even  mild  in  one  case,  while  ni  others  very  severe,  depending 
partly  upon  the  exciting'  causes,  which  may  be  very  manif(dd, 
namely : 

(a)  IiiflaiiiiiuUioJi  of  Ihc  vcrlcbrcc.  Examination  of  the 
back  detects  either  a  beginning  spondylitis  (impossiliilitx'  of  bend- 
ing the  back,  painfulness  upon  pressure  over  such  or  such  ver- 
tebra), or  very  pronounced  malum  Potti.  Abdoniiual  pains  occur 
m  attacks  and  especially  at  night. 

(b)  Lead  poisoniui^.  Gray  (lead)  line  on  the  gums,  ob- 
stinate constipation  not  yielding  to  common  remedies,  the  abdomen 
being  flat  or  concave,  and  hard  ;  the  urine  scanty,  of  high  specific 
_gravity  and  turbid  ;  history. 

(c)  General  iien-oiisiiess.  Nervous  abdominal  pains  de- 
pending upon  this  cause  occur  in  }outhful  girls  marked  by  pale- 
ness. They  usually  are  rather  thin,  eat  almost  nothing,  are  prone 
to  constipation  but  the  attacks  of  pain  do  not  depend  upon  cos- 
tiveness.  The  pains  are  repeated  at  different  hours  of  the  day 
whether  the  stomach  is  empty  or  not,  recurring  every  day,  or 
twice  or  three  times  a  week.  Sometimes  the  patient  suffers  from 
an  undoubted  hysteria. 

(  d)  The  cause  of  the  colics  may  also  be  a  eold  (  colica  rheii- 
iiiatica),  as  a  result  of  wetting  of  the  feet  or  of  the  whole  body. 
Diarrhoea  is  not  necessarily  present  in  such  conditions. 

(e)  Malaria.  J\Iay  be  a  positive  cause  of  regularly  return- 
ing abdominal  pains,  the  nervous  character  of  which  is  manifested 
by  being  entirely  independent  of  the  time  of  taking  food  and  of 
its  quality.  If  the  paroxysm  is  violent,  then  it  may  be  associated 
with  vomiting.  Tumor  of  the  spleen,  and  especially  elevation  of 
temperature  may  be  absent.  These  pains  are  peculiar  in  other  re- 
spects than  belonging  to  their  periodicity,  for  example,  by  their 
obstinacy  regarding  opium,  laxatives,  diet,  etc.,  and  their  quick 
disappearance  after  some  doses  of  quinine.  In  one  eleven-year- 
old  girl  I  observed  the  interesting  alternation  of  the  attacks :  the 
■disease  began  with  regular  paroxysms  of  quotidian  fever  which 
disappeared  after  quinine,  but  a  few  days  later  the  patient  began 
to  suffer  daily  from  migraine  which  would  start  at  two  o'clock 
in  the  afternoon,  but  yield  readily  to  quinine;  after  a  few  days 
more  periodical  abdominal  pain  developed  severe  enough  to  cause 
the  patient  to  cry. 


2l6  SEMEIOLOGY    OF    ABDOMINAL    PAIN 

Among  purely  nervous  colics  one  must  also  include  ab- 
dominal pain  sometimes  occurring  during  the  period  of  recovery 
from  diphtheria,  and  depending  perhaps  upon  an  affection  of  the 
vagus  nerve,  because  such  a  pain  usually  precedes,  according  to 
Suss*,  sudden  death  from  heart  paralysis  and  has  therefore  an 
unfavorable  prognostic  meaning  (seepage  158). 

Before  the  diagnosis  of  nervous  abdominal  pain  is  made  one 
must  first  of  all  consider  renal  colic,  which  occurs  in  childhood, 
contrary  to  hepatic  colic,  not  very  infrequently.  Renal  colic  may 
be  suspected  if  attacks  of  abdominal  pain  appear  in  a  child  after 
irregular  intervals  of  time  (days,  weeks  or  even  months  may 
elapse  between  attacks)  ;  especially  after  bodily  jolting  (driving 
on  a  bad  street,  riding)  ;  if  the  child  be  well,  but  his  recent 
urine  contains  sand  :  and  if  there  is  some  tenderness  upon  pres- 
sure over  the  back  in  the  region  of  either  kidney.  The  pain 
during  the  attack  is  either  quite  bearable,  or  so  severe  that  cold 
perspiration  appears  on  the  face,  accompanied  willi  \oniiting  and 
failure  of  the  pulse.  The  diagnosis  of  renal  colic  becomes  still 
more  probable  if  the  microscopical  examination  of  the  urinarv 
sediment  reveals  pus  corpuscles,  mucus,  pelvic  epithelium,  in  l)rief, 
symptoms  of  pyelitis. 

The  most  diagnostic  sign  of  renal  colic  is  the  elimination 
of  a  small  stony  concrement  with  the  urine.  The  parents  of  such 
children  often  show  symptoms  of  uric-acid  diathesis  (podagra^ 
urinary  sand)  or  suffer  from  migraine.  If  in  a  family  consist- 
ing of  several  children  one  of  them  suffers  with  attacks  of  renal 
colic,  his  brothers  and  sisters  not  infrcquentl}'  present  evidences 
of  sand  in  the  recent  urine. 

The  youngest  child  in  which  I  had  the  opportunity  of  observ- 
ing renal  colic,  with  elimination  of  small  calculi,  was  about  three 
years  old. 

(4)  Xbdominal  pain,  due  to  renal  colic,  belongs  to  the 
fourth  division  of  our  classification,  that  is,  to  pain  because  of  irri- 
tation of  neighboring  organs,  but  not  of  the  bowels  themselves. 
Here  also  belongs  abdominal  pain  due  to  movable  kidney,  which,, 
although  rare,  occurs  in  children. 

Finally,  there  must  also  be  included  the  refiex  pains  of  the 

'■"Revue  mens,  des  mal,  de  I'euf.     1887.  page  289. 


SEMEIOLOGV    OF    AIIDO.M  1  XAL    PAIN  21/ 

abdomen  of  which  chilchx'ii  from  two  to  six  years  old  complain 
so  often  during-  pneumonia  and  pleuritis.  It  is  remarkable  that 
at  this  age  children  when  sick  with  pneumonia  crouposa  never 
complain  of  pain  in  the  side,  but  always  locate  the  same  in  the 
abdomen,  so  that  if  a  child,  complaining  of  abdominal  pain,  has 
fever,  cough  (dry),  while  the  respiration  is  accompanied  by 
movement  of  the  nostrils,  then  the  existence  of  pleuro-pneumonia 
is  highly  probable. 

[This  referred  pain  may  be  explained,  according  to  Herrick, 
in  his  instructive  paper,*  in  the  following  way :  The  lower  six 
intercostal  nerves — the  anterior  divisions  of  the  dorsal  nerves  — 
supply  the  abdominal  wall,  as  well  as  a  part  of  the  parietal  and 
diaphragmatic  pleura.  An  irritation,  i.  e.,  from  inflammation  or 
pressure,  in  the  course  of  one  of  these  nerves  might  readily  cause 
a  pain  that  would  be  referred  to  the  distribution  of  this  nerve, 
i.  e.,  to  the  abdominal  wall.  *  *  *  The  eleventh  nerve  is 
distributed  over  the  iliac  region.  Pain  here  would  easily  make 
one  think  of  the  appendix,  if  on  the  right  side,  or,  if  on  the  left, 
perhaps  of  the  rarer  left-sided  appendicular  pains.  The  other 
nerves  would  cause  pain  referred  to  the  umbilical,  epigastric  or 
hypochondriac  regions  and  the  confusion  that  might  result  when 
we  think  of  the  possible  significance  of  such  pain  in  the  way  of 
ulcer  of  the  stomach,  gall  bladder  mischief,  pancreatitis,  etc.,  is 
clearly  seen. — Earle.] 


*Herrick:    Abdominal    pain   in   pleurisy   and   pneumonia    (Jour.   Amer. 
Med.  Assoc,  Aug.  29,  1903). 


SEMEIOLOGY   OF    THE   ENLARGED  AB- 
DOMEN. 

Normally,  that  is.  if  the  abdomen  is  neither  distended  nor 
sunken,  the  abdominal  walls  durinjj  the  recumbent  posture  of  the 
patient  should  be  somewhat  lower  than  the  lower  level  of  the 
chest,  or  at  the  same  level,  as  ha])pens  with  fat  children  ;  if.  how- 
ever, the  abdomen  be  hi.e^her  than  the  arch-rib,  then  one  is  justified 
in  saying-  the  abdomen  is  enlarf^ed. 

An  enlarged  abdomen  may  depend  upon  distension  of  the 
bowels  because  of  flatus,  or  upon  an  accumulation  of  fluid  in  the 
abdominal  cavity.  It  is  not  difficult  to  differentiate  these  condi- 
tions. In  meteorism  the  abdomen  everywhere  gives  a  tympanitic 
note  on  percussion,  while  in  dropsy  a  dull  sound  is  obtained  /;/  fhr 
dependent  parts,  changing  its  location  u])on  a  change  of  ])()si- 
tion  of  the  patient  (provided  there  are  no  adhesions  to  prevent 
the  fluid  flowing  from  one  part  to  another).  Fluctuation  is  readily 
determined  by  one  hand  being  placed  upon  one  side  of  the  ab- 
domen, while  the  opposite  side  is  lightly  struck  with  the  fingers  of 
the  other  hand.  If  the  abdominal  walls  are  tense,  then  their  con- 
cussion may  give  false  fluctuation  in  a  common  meteorism.  One 
may  be  guided  in  such  duubtful  cases  In-  the  character  of  the 
wave  which  is  produced  by  striking  the  abdominal  wall :  in  the 
presence  of  accumulation  of  fluid,  that  is.  in  a  real  fluctuation, 
one  may  distinctly  determine  that  the  size  of  the  wave  which 
impinges  ui:)on  the  hand  applied  to  the  abdomen  changes.  dei)end- 
ing  upon  whether  the  tapping  is  done  with  one  finger  or  with  tli." 
ends  of  several  fingers :  in  the  former  case  the  wave  will  be  a 
small  one,  in  the  latter  comparatively  large.  In  false  fluctuation 
the  concussion  of  the  abdominal  wall  is  not  perceptible  enough 
to  enable  one  to  appreciate  the  size  of  the  striking  surface  of 
the  fingers. 

One  may  sometimes  obtain  an  undoubted  fluctuation  in  the 
abdomen  notwithstanding  the  complete  absence  of  ascites.  This 
occurs  in  cases  of  accumulation  of  fluid  in  anv  sac.  whatever  it 


SKMi:ii)i.o(;\-  OF  THE  Kxi,AR(;i:r)  AUDDisrEN  219 

may  be,  hxdronephrosis,  disteiuled  bhuk'er,  or  ovarian  c\sl.  Tii 
-all  these  cases  the  dull  sound  docs  not  change  its  boundaries  witli 
a  change  m  the  position  of  the  patient. 

A  distended  bladder  is  easily  outlined  it  the  abdominal  walls 
are  not  tense  and  fat,  so  that  it  is  convenient  to  palpate  the  boun- 
daries of  the  bladder  through  them.  It.  however,  these  boundaries 
cannot  be  felt  then  the  diagnosis  is  decided  by  the  form  of  the 
dull  sound  which  occupies  the  space  in  the  median  line  of  the 
abdomen  between  the  navel  and  symphysis  pubis  spreading  several 
inches,  symmetrically,  to  both  sides  from  this  line.  This  dull  note 
docs  not  change  its  boundaries  on  changing  the  position  of  the 
patient,  but  disappears  after  evacuation  of  the  urine  through  -i 
catheter. 

Hydronephrosis  and  ovarian  c_\st  will  be  referred  to  in  the 
•description  of  Tumors  of  the  Abdomen. 

Distension  of  the  abdomen  develops  either  acutely — 
metcorism,  or  exists  in  a  chronic  form — tympanites. 

Acute  meteorism  in  moderate  degree  generally  accoinpanies 
acute  catarrh  of  the  small  bowels  and  dyspepsia  in  small  chiUlren, 
as  well  as  in  occasionally-occurring  constipation.  Considerable 
development  of  meteorism  is  to  be  noted  during  more  serious 
■diseases,  as  intestinal  obstruction  (invagination)  and  inflammation 
•of  the  peritoneum,  local  as  well  as  general. 

The  diagnostic  meaning  of  meteorism  is,  generally  speaking, 
not  great,  playing  in  this  regard  a  secondary  part,  because  other 
more  important  diagnostic- symptoms  are  then  present.  How- 
ever, in  some  cases  it  may  aid  the  diagnosis,  for  instance,  in  doubt- 
ful forms  of  typhoid,  resembling  tubercular  meningitis ;  here  a 
moderate  meteorism  is  in  favor  of  typhoid,  while  a  slightly 
sunken  abdomen  is  more  significant  of  meningitis. 

Chronic  tympanites  occurs  in  chonic  intestinal  diseases  (diar- 
rhcea  or  constipation),  as  well  as  in  chronic  peritonitis  (together 
with  ascites,  see  below),  and  in  man}-  cases  of  rachitis.  The  activ- 
ity of  the  bowels  being  normal,  tympanites  may  depend,  in  chil- 
■dren,  upon  indigestible  vegetable  fcxid,  consisting  chiefly  of  bread 
and  potatoes. 

Dropsy  of  the  abdomen.  Accunudation  of  fluid  in  the  ab- 
domen may  be  the  consequence  of  a  transudation  into  the  abdom- 
-inal  cavity  due  to  an  obstructed  circulatic^n  in  the  vena  porta,  or 


220  SKMKIOLOCY    OF   THE   KXLARC.ED   ABDOMEN 

to  general  hydrasniia  and  alteration  of  the  walls  of  the  vessels- 
(Cohnheim)  ;  or,  again,  fluid  accumulating  in  the  abdomen  is  the 
result  of  peritonitis,  this  being  in  the  form  of  exudate. 

A  simple,  that  is,  not  inflammatory  dropsy  of  the  abdome)'., 
which  depends  upon  hydrccniia,  is  characterized,  first,  by  the  co- 
incident presence  of  anasarca,  which  either  involves  the  whole 
body  or  only  some  parts,  as  the  face  and  the  feet;  second,  by  the 
fact  that  it  is  always  possible  to  find  the  cause  of  hydraemia  either 
in  inflammation  of  the  kidneys  (examina.tion  of  the  urine)  or  in 
the  wasting  diseases,  chief  among  which  is  chronic  diarrhoea 
(follicular  enteritis). 

In  other  cases  ascites,  as  one  of  the  sequela;  of  general  dropsy, 
is  the  consequence  c^f  obstructed  circitlatioii  in  general,  and  espe- 
cially in  the  liver;  the  cause  must  then  be  looked  for  in  cardiac 
lesions  or  in  chonic  atYecti(Mis  of  the  lungs  and  especially  of  the 
pleura  (suppurati\e  ])leuriiisi.  In  the  latter  case  the  dropsy  may 
be  produced  by  a  double  cause,  that  is,  by  obstructed  circulation 
and  by  hydraemia  due  to  marasmus. 

We  may  then  only  diagnose  a  stagnant  abdominal  dropsy  in 
cases  where  there  are  also  symptoms  of  passive  hyperaimia  of  the 
liver  (see  Tumors  of  the  Liver). 

Some  difficult}'  in  diagnosis  may  be  exhibited  by  cases  of 
inflammatory  ascites,  when  appearing  in  hydropic  persons.  Such 
a  com.bination  of  chronic  serous  j>eritonitis  is  observed,  first,  in 
chronic  nephritis  and,  second,  in  tuberculosis.  In  the  former  case,, 
in  a  seven-year-old  girl,  the  diagnosis  was  based  chiefly  on  the 
peculiarities  of  the  aspirated  fluid,  which  appeared  turbid  because 
of  admixture  with  great  quantities  of  pus  corpuscles  and  con- 
tained much  albumen.  In  a  tulierculous  boy,  ten  years  old.  the 
diagnosis  of  peritonitis  in  the  presence  of  general  dropsy  could 
be  established  on  the  ground  of  adhesions  between  the  bowels  and 
the  abdominal  wall,  so  that  the  free  moving  of  the  fluid  on  change 
of  position  of  the  patient  was  limited.  There  remained  a  tympan- 
itic note  in  the  right  epigastrium  during  the  erect  posture  of  the 
patient,  as  well  as  during  a  position  on  the  right  side,  notwith- 
standing the  very  small  amount  of  fluid  in  the  abdomen.  An  iti- 
duration  could  be  felt  at  the  same  place. 

The  diagnosis  was  verified  in  both  cases  by  the  post-mortem. 

In  a  third  case,  which  did  not  end  fatally,  we  had  an  ascites. 


SEMEIOLOGY   OF   THE   ENLAR(;i:n   AI'.DOMEN  221 

^n  a  ten-year-old  girl  who  suffered  from  chronic  nephritis  and 
'diarrhoea.  Although  the  ascites  here  was  a  part  of  the  general 
dropsy,  yet  it  probably  was  also,  in  part  at  least,  of  inflammatory 
orig-in,  because  the  fluid  drawn  off  by  means  of  a  trocar  was  very 
turbid  from  the  admixture  of  pus  corpuscles  and,  besides  this,  the 
ascites  was  disproportionately  great  in  comparison  with  the 
•oedema  of  the  feet. 

Rehn*  asserts  that  exudative  peritonites,  sometimes  arising 
during  renal  affections,  are  characterized  by  fever  and  painfulncss 
in  the  abdomen ;  but  these  signs  are  of  but  little  importance  in 
chronic  cases,  because  both  may  be  absent,  and  in  tuberculous 
patients  the  fever  may  depend  upon  other  causes. 

But  in  such  cases  of  combined  ascites,  although  rare,  the 
diagnosis  of  the  cause  of  the  ascites,  which  constitutes  a  part  of 
general  dropsy,  is,  generally  speaking,  not  difflcult.  Much  greater 
difficulties  are  exhibited  in  this  regard  by  isolated  ascites,  when 
the  question  arises  whether  we  have  a  stagnant  ascites,  that  is, 
transudation,  or  a  chronic  exudative  peritonitis.  The  diagnosis 
■of  both  these  morbid  conditions  may  be  made  from  analysis  of 
the  aspirated  fluid,  by  the  aetiology  and  the  history,  as  well  as  by 
the  symptoms. 

The  transudate  is  a  transparent,  slightly  yellowish  fluid, 
■whose  specific  gravity  is  less  than  1015,  the  quantity  of  albumen 
not  exceeding  two  or  three  per  cent ;  while  an  exudative  fluid, 
although  sometimes  also  transparent  (is  usually  turbid,  grossly 
resembling  water  slightly  whitened  with  milk,  because  of  the 
more  or  less  considerable  admixture  of  pus  corpuscles),  con- 
tains much  albumen  (four  to  six  per  cent)  and  the  specific  gravity 
is  more  than  1015. 

Fever  and  abdominal  pain  indicate  peritonitis,  but  the  absence 
■of  these  symptoms  does  not  exclude  the  latter. 

Reuss  found  that  the  difference  in  the  specific  gravity  be- 
tween a  transudate  and  an  exudate  depends  especially  upon  the 
-quantity  of  albumen,  so  that  the  amount  of  the  latter  may  be 
judged  from  the  specific  gravity.  Reuss  even  gives  a  formula 
for  determining  the  amount  of  albumen :  if  S  signifies  the  specific 
gravity  and  E  the  amount  of  albumen  in  per  cent,  then  E  equals 


*Handbucli  v.  Gerhardt,  Vol.  IV.,  1880,  p.  258. 


222  SEMEIOLOGY   OF   THE   ENLARGED   ABDOMEN 

^x(S-i,ooo)-2.8.  If,  for  instance,  the  specific  gravity  of  the 
transudate  is  equal  to  lOlO,  then  E  equals  fi  x  10-2.8;=^- 
2.8  or  E  equals  0.95 

If  a  fluid  drawn  from  any  cavity  coagulates  after  long  stand- 
ing, then  it  is,  of  course,  an  exudate ;  if  it  does  not  coagulate,  then 
such  fact  does  not,  per  se,  exclude  its  character  of  an  exudate. 

Transudation  in  the  abdominal  cavity,  in  an  isolated  ascites;: 
is  always  of  passive  origin  due  to  compression  of  the  vena  porta 
or  its  hepatic  branches.  Such  a  dropsy  of  the  abdomen  rarely 
occurs  in  childhood. 

Comparatively  more  frequent  causes  of  ascites  are  produced 
by  diseases  of  the  liver. 

Syphilis  of  the  liver  is  characterized  in  older  children  by 
enlargement  of  the  organ,  the  formation  of  gummous  nodes  and 
cicatricial  connective  tissue,  so  that  the  liver  assumes  a  lobular 
shape.  This  malady  may  be  supposed,  or  even  diagnosticated^ 
if  the  child  had  previously  suffered  with  symptoms  of  hereditary 
syphilis  (abortions  in  the  mother,  eruption  during  the  first  year  of 
life,  later  on  ulcerous  processes  of  the  long  bones)  and  at  present 
time  an  enlarged  nodular  liver  may  be  palpated.  The  diagnosis- 
becomes  confirmed  if  under  the  influence  of  specific  treatment 
(iodide  of  potash)  for  a  few  weeks  the  ascites  disappears,  the 
liver  decreases  in  volume  and  the  general  aspect  of  the  patient 
improves. 

Simple  cirrhosis  of  the  liver  develops  in  children  who 
have  been  given  wine,  or,  even  without  this  setiological 
factor,  after  acute  infectious  diseases.  [The  cause  of  infan- 
tile cirrhosis  of  the  liver  often  lies  in  the  congenital  oblit- 
eration of  the  bile  ducts  (over  seventy  cases  are  recorded 
in  connection  with  this  aetiology)  and  congenital  syphilis. 
Alcohol  was  found  by  Morse*  to  be  an  setiological  factor  in 
ten  to  twenty-five  per  cent,  of  all  cases.  The  eruptive  fevers  rare- 
ly, if  ever,  produce  hepatic  cirrhosis. — Earle.]  In  the  symptoms- 
this  form  differs  but  little  from  the  hepatic  cirrhosis  of  adults.  Re- 
garding the  diagnosis  it  is  important  to  note  that,  in  the  first 
period  of  the  disease,  disorder  of  digestion  is  commonly  found  in 
the  form  of  diarrhoea  alternating  with  constipation,  together  with 


^Boston  Med.  and  Surg.  Jounial,  Sept.  ii,  1902. 


sEiM]-:i()i.()r.v  OF   riii-:  i-.xlarced  abdijmkn  223 

abdominal  pains.  Tlicse  symptoms  arr  the  same  as  we  always  find 
in  the  history  of  ascites  due  to  tubercular  peritonitis,  but  they  are 
absent  in  the  so-called  idiopathic  ascites  due  to  chronic  serous  peri- 
tonitis. 

Not  less  important  is  it  to  note,  in  the  history,  the  occurrence 
of  jaundice,  wdiich  is  rarely  absent,  being  sometimes  moderately 
developed  and  transient,  with  relapses ;  although  it  may  not  be 
present  in  any  given  case  in  the  period  of  a  very  pronounced 
ascites. 

With  great  probability  one  may  diagnose  hepatic  cirrhosis, 
provided  gradual  diminution  of  the  liver  and  enlargement  of  the 
spleen  are  noticeable.  Unfortunately  the  presence  of  the  great 
quantity  of  fluid  in  the  abdomen  considerably  hampers  the  exam- 
ination, or  renders  it  negative,  unless  paracentesis  is  performed. 

Amyloid  liver  never  occurs  as  an  independent  lesion,  but 
only  in  exhausted  children  and  especially  in  scrofulous  ones,  suf- 
fering wdth  ulcerous  processes  in  the  bones  or  upon  the  skin, 
as  well  as  in  tuberculosis,  s}philitic  and  generally  in  cachectic 
conditions  after  wasting  diseases.  In  the  presence  of  such  aetio- 
logical  criteria,  it  is  not  difficult  to  recognize  an  amyloid  liver. 
Such  a  liver  is  very  large  (reaching  not  infrequently  to  the  navel) 
is  firm  and  hard,  the  margins  are  rounded,  the  surface  smooth  and 
painless  upon  pressure.  As  the  amyloid  degeneration  almost 
never  is  limited  to  the  liver  alone,  spreading  also  to  the  kidneys 
and  spleen,  therefore  a  large  spleen  together  with  albuminuria 
may  be  held  as  characteristic  symptoms  of  an  amyloid  liver. 
Jaundice  is  absent  if  there  are  no  complications.  Regarding 
ascites,  it  must  be  said  that  this  is  not  a  constant  symptom  of  the 
disease  in  question.  As  the  dropsy  often  begins  from  the  feet, 
the  abdomen  becoming  involved  later  on,  one  may  think  that  in 
many  cases  of  ascites  due  to  amvloid  liver  the  main  influence  in 
its  origin  is  not  the  obstructed  hepatic  circulation,  but  merely 
hydremia. 

It  is  also  difficult  to  say  what  influence,  in  the  formation  of 
ascites,  may  be  produced  by  hyperplastic  hai'deniiig  of  the  iher, 
one  of  the  symptoms  of  malarial  cachexia,  the  diagnosis  of  which 
is  based  especially  on  the  history  (continued  malaria).  Large, 
hard   spleen,   with  a   considerably  enlarged  and   also  hard   liver 


224  SEMEIOLOGV    OF   THE    EXLARCiED   ABDOMEX 

whose  surface  is  even  and,  finally,  cedenia  of  the  feet  and  general 
anaemia,  constitute  the  picture  of  the  disease. 

Regarding  ascites  due  to  compression  of  the  vena  porta  by 
enlarged  glands  in  the  porta  hepatis,  or  of  the  inferior  vena  cava 
higher  than  the  point  of  entrance  of  the  hepatic  veins,  it  may  be 
said  that  the  diagnosis  is  impossible.  As  the  enlargement  of  the 
lymphatic  glands  depends  either  upon  amyloid  degeneration  anrl 
tuberculosis,  or  upon  degeneration  because  of  cancer  of  adjacent 
organs,  then  such  cause  cannot  be  suspected,  if  the  patient  does 
not  appear  exhausted  and  if  the  history  does  not  show  any  pos- 
sibility of  degeneration  of  the  glands.  One  may  be  guided  by 
these  circumstances  in  the  differential  diagnosis  of  a  simple  ser- 
ous peritonitis. 

Exudative  ascites.  Drops\  of  the  abdomen  as  a  result  cf 
chronic  peritonitis  occurs  in  children  much  oftener  than  obstructive 
dropsy.  Chronic  peritonitis,  as  a  consequence  of  an  acute,  com- 
mon peritonitis,  occurs  quite  seldom.  As  an  example  I  refer  to 
the  following  case: 

A  deaf-mute,  ten-year-old  boy,  of  healthy  parents,  previously 
in  good  health,  brothers  also  entirely  well,  never  suft'ered  from 
prolonged  diarrhoea,  cough,  or  abdominal  pain.  He  entered  the 
hospital  on  account  of  pain  and  distension  of  the  abdomen.  The 
disease  began  about  a  month  previously,  after  drinking  some 
cold  beer  while  in  a  heated  state.  The  disease  started  with  fever, 
repeated  vomiting  and  such  violent  abdominal  pain  that  he  was 
compelled  to  keep  an  immovable  recumbent  posture  (on  the  back) 
A  few  days  later  his  father  noticed  a  considerable  enlargement  of 
the  abdomen.  Since  that  time  the  patient  has  not  left  his  bed,  being 
taken  to  the  hospital  a  month  after  the  beginning  of  the  disease, 
when  the  abdominal  pain  had  abated  considerably  and  the  patient 
could  sit  up. 

At  the  time  of  entering  the  hospital  the  patient  was  pale  and 
thin,  but  far  from  being  exhausted,  the  abdomen  considerably 
enlarged  (66V2  ctm.),  painful  upon  pressure,  especially  between 
the  umbilicus  and  epigastrium,  where  one  could  easily  feel  a  hard- 
ening through  the  abdominal  wall,  with  a  well-defined,  firm  lower 
margin  which  very  much  resembled  the  margin  of  the  left  lobe  of 
a  hardened  liver.  This  margin  crossed  the  abdomen  two  inches 
higher  than  the  navel,   from  one  hypochondrium  to  the  other. 


SEMEIOLOGY   OF   THE   ENl.ARGI-.l)    Al'.DOMEN  225 

The  ii])pcr  iii;iri;in  of  the  tumor  did  not  reach  the  lower  end  of  the 
stenuini,  so  that  in  the  epigastrium  there  remained  a  small  ar(.'a 
of  less  resistence,  which  contraindicated  an  increased  liver.  The 
consistency  of  the  tumor  w'as  very  solid ;  the  surface  not  en- 
tirely even;  upon  pressure  it  was  painful.  L^pon  light  percussion 
of  the  tumor  a  tympanitic  sound,  as  of  the  bowels,  was  obtained, 
pointing"  to  a  limited  thickness  of  the  mass.  The  liver  could  not 
be  palpated ;  the  dull  note  of  the  liver  began  one  inch  below  the 
navel,  reaching  the  lower  margin  of  the  chest.  The  abdomen 
gave  a  distinct  fluctuation  and  a  dull  sound  on  percussing  the 
sides,  while  the  dullness  changed  upon  change  of  position  of  the 
patient.  The  tongue  was  clean,  humid ;  the  bowels  moved  once  a 
day,  normally ;  the  appetite  good.  The  urine  stained  intensely 
by  the  urinary  pigments  and  contained  much  indican ;  no  albumen. 
Splenic  dullness  could  be  determined.  Cough,  absent ;  sleep, 
fair;  fever,  constant  and  moderate  (37  to  37.7  degrees  C. — 98.6  to 
99.9  degrees  F.  in  the  morning,  and  about  10 1  degrees  F.  or 
38.5  degrees  C.  in  the  evening,  without  any  perspiration).  Gen- 
eral condition  fair :  the  patient  sat  easily  in  his  bed.  CEdema  of 
the  cellular  tissue  was  noticed  only  in  the  scrotum. 

The  diagnosis  of  simple  peritonitis  was  made  on  the  ground 
of  the  history  (acute  beginning,  absence  of  intestinal  catarrhs 
and  tuberculous  taint),  although  the  tumor  between  the  navel  and 
scrobiculum  cordis,  which  was  regarded  as  a  thickened  and  cica- 
trized omentum,  favored  tuberculosis. 

Several  days  later  the  patient  contracted  scarlet  fever,  to 
which  he  succumbed.  The  post-mortem  showed  in  the  abdomen 
the  presence  of  sero-purulent  fluid,  while  the  tumor  in  the  upper 
part  of  the  cavity  was  not  a,  degenerated  omentum,  but  merely 
a  greatly  thickened  peritoneum.  The  inflammatory  infiltration 
ended,  without  reaching  the  umbilicus,  with  a  very  thick  (as  a 
small  finger  )  vertical  margin,  which  simulated  the  margin  of  the 
liver.  There  were  no  traces  of  tuberculosis,  even  in  the  bronchial 
glands. 

The  difl:'erential  diagnosis  of  such  cases  from  tubercular 
peritonitis  is  reached  with  some  probability  only  from  the  facts 
contained  in  the  history. 

In  other  cases  chronic  serous  peritonitis  develops  independ- 
entl}-,  under  the  influence  of  unknown  causes,  or  an  undoubted 


226  SE.MKIOLOCV    OF    THE   ENLARGi:!)   ABDOMEN' 

cold  (Galvani),  and  proceeds  slowly  from  the  very  first,  without 
acute  sym])toms  of  irritation  of  the  peritoneum,  although  accom- 
panied at  the  beg"inning  with  fever.  Even  when  well  developed 
this  disease  does  not  lead  to  any  complications,  being  indicated 
by  no  other  symptoms  except  the  considerable  ascites,  therefore, 
formerly  described  as  idiopathic  ascites — ascites  idiopathica. 
Galvani  called  it  peritonitis  rhcumatica  serosa  chronica. 

Other  symptoms  are  negative:  the  abdomen  is  neither  tense, 
nor  painful,  its  form  being  spherical,  like  that  during  a  passive 
dropsy ;  no  hardening  or  adhesions,  so  that  the  boundaries  of  the 
dull  sound  change  freely  on  altering  the  position  of  the  patient. 

Besides  these  negative  symptoms,  serous  peritonitis  exclusive- 
ly afifects  healthy  children,  the  general  condition  remaining  good 
even  during  the  period  of  full  development  of  dropsy.  The  patient 
has  a  good  appetite,  moves  the  bowels  regularly  (according  to 
Baginsk}  there  Is  often  diarrhoea),  has  no  fever  and  is  not  con- 
fined to  bed,  by  which  this  disease  difi^ers  also  from  obstructive 
dropsy  due  to  diseases  of  the  liver,  wherein  the  general  condition 
always  sufifers  rapidly.. 

The  usual  termination  of  this  form  of  peritonitis  is  in  recov- 
ery, although  death  is  also  possible,  as  liappened,  for  instance,  in 
the  following  case : 

A  boy,  aged  four  years  and  three  months,  entered  the  clinic 
in  September,  on  account  of  an  enlarged  abdomen.  The  parents 
of  the  patient  were  young  and  healthy  ])eo])le  ( the  father  thirty 
years  old,  the  mother  twenty-four)  ;  tuberculosis,  syphilis  or  men- 
tal diseases  absent  in  the  famih.  ( )f  two  children,  the  first  one, 
a  girl,  died  when  eight  months  old  from  diarrhcea,  the  second, 
our  patient,  was  born  at  full  term,  was  fed  from  the  mother's 
breast  eight  months,  the  first  teeth  appeared  in  the  eighth  month ; 
he  began  to  walk  at  the  beginning  of  the  second  year.  Had  pneu- 
monia twice,  when  ten  and  eighteen  months  old,  after  that  w^as 
well  until  five  months  ago.  On  April  15  was  taken  with  fever, 
temperature  40  degrees  C.  (104  degrees  F.),  and  cough,  but  soon 
recovered.  Two  months  later,  about  the  middle  of  June,  the 
mother  began  to  notice  morning  oedema  of  the  eyelids,  and  a  few 
days  later  her  attention  was  called  to  enlargement  of  the  ab- 
<lomen.  This  was  three  months  before  entrance  to  the  chnic. 
Durmg  all  this  time  the  patient  was  up ;  no  noticeable  fever  was 


sKMi.ioi.dC.N    OF  Till-:  i':.\i,.\R(;i:i)  .\1!I)I).mi-:n  227 

present,  hul  llic  a])])etite  somewhat  decreased;  some  pallor  and 
wastino^  developed.  Status  prccseiis:  The  patient  is  rather  thin 
and  pale;  the  wcioht  is  only  32^/2  pounds;  traces  of  rachitis  on 
the  chest ;  the  lymphatic  glands  of  the  neck  and  other  Ir^cations 
not  enlarged  ;  the  tongue  clean  ;  appetite  poor  ( the  patient  is  sat- 
isfied with  two  cups  of  milk,  a  few  tahlespoonfnls  of  soup  and 
milk  gruel)  ;  neither  vomiting  nor  nausea;  the  bowels  move  sev- 
eral times  a  day  normally.  The  abdomen  is  considerabl\  eiilai'i^ed 
(at  the  widest  part  fift)'-seven  centimeters)  spherleal  in  form, 
painless  upon  pressure;  the  walls  are  not  tense,  so  that  one  can 
palpate  the  thin,  tender  margin  of  the  slightly  enlarged  liver.  The 
spleen  is  not  palpable:  fiuetuafion  distinctly  proves  the  presence 
cf  fluid  in  the  abdominal  cavity,  always  occupying  the  sides  of 
the  abdomen  on  change  of  position  of  the.  patient,  .so  that  it  is 
•entirely  free,  not  encapsulated  ;  no  hardeniui^s  or  tumors  are  to 
be  detected  in  the  abdomen;  the  hver  passes  the  hypochondrium 
about  three  fingers  breadth ;  its  margins  and  anterior  surface  are 
smooth  and  of  normal  firmness ;  the  upper  limits  of  dullness  reach 
the  sixth  rib.  The  dull  sound  of  the  spleen  was  deadened  bv 
the  tympanitic  note  of  the  bowels.  Percussion  and  auscultation 
of  the  heart  and  lungs  give  normal  results  ;  no  cough,  but  the 
respiration  is  accelerated  (40  to  44),  the  pulse  112;  the  temper- 
ature in  ano  37  degrees  C.  to  37.2  degrees  C.  (98.6  to  99  degrees 
F.)  ;  no  perspiration;  the  urine  acid,  no  albumen  and  without 
sediment ;  sleep  good  ;  no  headache. 

The  patient  remained  in  the  hospital  three  and  a  half  months, 
and  no  changes  were  noted  all  this  time  until  laparotomy  was  per- 
formed (December  6).  The  sutures  were  removed  after  one 
week,  and  five  days  later  the  patient  was  allowed  to  walk.  The 
circumference  of  the  abdomen  was,  after  the  operation,  44 ;  a 
week  later,  47;  after  three  days  more,  48.  On  December  21  the 
patient  left  the  hospital  in  a  good  general  condition,  but  with 
fiuid  in  the  abdomen.  In  February  he  had  la  grippe  with  inflam- 
mation of  the  lower  lobe  of  the  left  lung,  after  which  the  abdomen 
became  enlarged  up  to  62 ;  the  temperature  having  been  nomial ; 
the  appetite,  fair ;  stool,  normal ;  the  abdomen,  painless,  the  spirrrs, 
good ;  the  patient  up  during  the  whole  day. 

Six  months  later  the  patient,  suffering  with  an  immense 
ascites,  was  taken  to  another  hospital,  and  there  died.     The  post- 


228  SEMKIOLOr.V    OF   THK   EXL.\R(;ED   AJJDOMIiX 

mortem  showed  that  the  abdomen  was  thickened  with  inflamma- 
torv  deposits,  being  entirely  free  from  tuberculosis.  Guinea-pigs 
inoculated  with  the  ascitic  fluid  ( into  the  abdominal  cavity)  have 
not  contracted  tuberculosis. 

This  case  is  cited  minutely  because  at  the  present  time  some 
physicians*  doubt  that  non-specific  chronic  peritonitis  exists,  re- 
ferring all  such  apparent  cases  to  tuberculosis ;  while  this  instance 
proves  that  a  non-specific  chronic  peritonitis  may  obtain. 

Serous  peritonitis  differs  from  stagnant  dropsy  of  the  ab- 
domen by  the  absence  of  tumor  of  the  liver,  by  a  comparatively 
good  general  condition  and  by  the  absence,  in  the  history  and  in 
the  present  status,  of  any  specific  aff'ection. 

.\lucli  greater  similarity  to  serous  peritonitis  is  presented  by 
ascites  due  to  atroi)hic  cirrhosis  of  the  liver,  the  more  so  because 
the  liver  may  appear  decreased**  in  peritonitis,  for  under  the  in- 
fluence of  ascites  the  liver  turns  somewhat  on  its  axis,  its  lower 
border  being  pushcil  forward,  so  that  the  dull  sound  seems  de- 
creased. 

Tn  favor  of  serous  peritonitis  is  the  absence  of  any  traces  of 
icterus;  the  normal  size  of  the  .j/'/<?(7/;> stationary  condition  of  the 
ascites  and  the  good  general  condition  of  nutrition  covering  a 
long  period  of  time ;  the  absence  of  diarrhoea ;  and  partly  the  age 
of  the  child  (serous  peritonitis  especially  occurring  in  small  chil- 
dren under  five  years,  cirrhosis  of  the  liver  in  those  older). 

The  diagnosis  may  be  finally  determined  by  paracentesis  of 
the  abdomen,  for  two  reasons  in  j^articular;  first,  it  is  more  con- 
venient to  examine  the  liver  after  the  fluid  is  drawn  off;  and, 
second,  positive  results  may  be  obtained  upon  examination  of  the 
fluid,  regarding  its  specific  gravity,  quantity  of  albumen  and  the 
microscopical  properties  (admixture  of  pus  corpuscles  in  the 
exudate).  The  specific  gravity  of  a  transudation  is  no  more  than 
loio  to  1012;  in  serous  peritonitis  1015  or  more. 

Chronic  tubercular  peritonitis  occurs  as  the  most  fre- 
quent cause  of  isolated  ascites  in  children.  Its  development  is 
usually  preceded  by  chronic  diarrhoea  and  abdominal  pains,  altei^- 


*See,  for  instance,  Traite  des  maladies  de  I'enfance,  par  Grancher, 
Comby  et  Marfan,  Vol.  III.,  page  75. 

**But,  in  atrophic  cirrhosis  of  the  liver  in  childhood  the  liver  may  be 
increased  even  in  the  period  of  dropsy. 


SEMEIOLOGV    OF    TIIK    KX  I.  AR(  ;i:i )   AliDO.MI-'.X  229 

natin^;"  with  constipation.  The  child  a[)pcars  scrofulous  ( chronic 
eczema,  adenites,  diseases  of  tlic  bones),  or  comes  from  a  family 
with  a  tubercular  predisposition.  If,  such  conditions  being  present, 
ascites  arise,  associated  with  considerable  tension  of  the  abdominal 
walls,  so  that  the  abdomen  becomes  somewhat  compressed  at  the 
'sides  and  oval  in  shape  (l)ut  not  spherical  as  in  tympanites  or 
stagnant  ascites)  with  the  navel  prominent,  then  one  may  sus- 
pect with  great  probability  the  beginning  of  tubercular  peri- 
tonitis. 

\"omiting,  as  well  as  violent  pain  on  pressure  over  the  ab- 
domen, may  be  absent,  and  usually  is  absent ;  more  often  colic-like 
pains  occur,  but  upon  pressure  there  is  onl\-  a  slight  distress. 

As  the  morbid  process  develops,  the  diagnosis  becomes  easier. 
The  abdomen  is  considerabl\'  increased,  partly  because  of  meteor- 
ism,  partly  because  of  accumulation  of  fluid  :  the  abdominal  walls 
are  tense,  the  cutaneous  veins  of  the  abdomen  are  distended  :  on 
palpating  one  may  feel  in  dififerent  parts  of  the  abdomen,  or  in 
one  place,  either  an  induration  without  well-defined  limits,  or 
nodular  tumors.  At  these  points  the  abdomen  is  always  painful 
upon  pressure.  If  these  hardenings  depend  upon  concretions  in 
the  intestines,  along  with  the  thickened  abdomen,  then  the  cor- 
responding area  always  gives  a  tympanitic  sound  in  any  position 
of  the  patient.  Similar  symptoms  never  occur  during  stagnant 
ascites ;  the  fluid  moves  freely  in  the  cavity,  and  in  the  sides  a  dull 
sound  is.  therefore,  always  obtained. 

Furthermore,  in  tubercular  peritonitis  the  wasting  of  the 
patient  is  characteristic,  more  visible  in  the  extremities,  chest  and 
neck,  and  less  so  on  the  face,  so  that  the  disease  may  be  diagnosed 
par  distance,  in  view  of  the  contrast  between  the  large  abdomen 
and  the  general  wasting.  Of  importance  is  the  fever,  with  almost 
normal  and  even  subnormal  morning  temperature  and  evening 
elevations  up  to  38.5  to  39  degrees  C.  ( 101.3  to  102.2  degrees  F.). 
Sometimes  the  fever  stops  for  a  few  da}"s,  and  then  appears  again. 

In  diagnosing  tubercular  peritonitis  one  must  not  be  confused 
by  the  absence  of  cough  and  general  symptoms  of  tuberculosis  in 
the  patient.  The  main  thing  is,  that  in  childhood  the  lungs  are 
not  the  favorite  place  for  the  localization  of  the  tubercle  bacilli, 
and,  therefore,  it  often  happens  that  tubercular  peritonitis,  and 
still  more  often   meningitis,  appears  as  an   isolated   disease.     It 


230 


SEMEIOLOC.Y    OF    THE   ENLARGED   ABDOMEN 


occurs  more  rarely  that  in  tuberculosis  or  peritonitis  some  intes- 
tinal affections  in  the  form  of  chronic  catarrh  or  tubercular  ulcers^ 
are  absent,  because  the  affection  of  the  peritoneum  with  tubercu- 
losis usually  follows  a  like  condition  in  the  bowels  or  mesenteric 
glands.  Therefore,  one  almost  always  succeeds  in  finding  in  the 
history  of  a  tubercular  peritonitis  that  the  patient  formerly  suf- 
fered with  diarrhoea  and  abdominal  pain.  This  fact  may  occa- 
sionally serve  for  the  differential  diagnosis  from  a  simple  chronic 
peritonitis. 

For  comparison  we  will  present  the  symptoms  of  chronic  non- 
specific and  specific  tubercular  peritonitis. 

/Etiology. 

Peritonitis  tuhcrculosci. 
Occurs  in  sick  children  coming 
from  a  tubercular  family  or  suffer- 
ing from  any  tubercular  affection 
of  the  bones  or  internal  organ>^. 
The  history  gives  frequent  diar- 
rhoea with  abdominal  pains. 


Peritonitis  chronica  serosa. 
In  children  free  from  tubercu- 
lous taint  and  tuberculosis  of  oth- 
er organs.  In  the  history  may  be 
noted,  shortly  before  the  ascites, 
the  influence  of  cold  (laying  on 
damp  ground,  wetting  of  the  cloth- 
ing) or  of  acute  infectious  diseases 
(typhoid,  measles). 
Symptoms. 


The  general  nutrition  suffers  se- 
verely ;  after  two  or  three  months, 
with  the  beginning  of  the  en  arge- 
ment  of  the  abdomen  the  patient 
becomes  thin,  the  skin  on  the  in- 
ner surface  of  the  thighs  hangs  in 
folds,  the  face  is  very  pale. 

Tlic  form  of  the  abdomen  is 
oval.  The  abdominal  :vall  is  tense, 
painful  upon  pressure  over  some 
points,  and  hardenings  are  fe't, 
most  often  between  the  epigas- 
trium and  na\'el. 

Dull  sound  does  not  change  its 
boundaries  on  change  of  position 
of  the  patient,  because  of  perito- 
nitic  adhesions  in  the  abdomen. 

Fever  is  always  well-developed. 


The  general  nutrition  suffers  lit- 
tle. After  two  or  three  month.> 
from  the  beginning  of  the  disease 
there  yet  remains  a  good  quantity" 
of  the  subcutaneous  fat,  so  that 
the  skin  of  the  thighs  is  not  loose. 


Tlie  form  of  the  abdomen  is 
spherical.  The  abdominal  zvall  is- 
not  tense ;  no  painfulness  upon 
pressure  ;  no  hardenings  to  be  felt. 


The  du'l  sound  always  occupies- 
the  dependent  parts. 


Fever  is  only  noted  in  the  be- 
ginning ;  thereafter  the  tempera- 
ture remains  normal. 


The  Course. 
Leads  to  progiessive  wasting  of  Stationary  for     many     months; 

the  organism,  ending  usually  with  usually   ends   with    recovery   after 

death  after  six  to  twelve  months,  four  to  six  months,  but  fatal  ter- 

although  recovery  is  possib  e.  mination  is  also  possib'e. 


si-:.\[F-:i()[.()r.v  hf  the  i;.\i..\rc,i-:i)  .\i!nit.\ii;x  2:^1 

[Kissel*  presents  the  following-  conclusions  as  regards  dia.G^- 
nosis  of  tubercular  peritonitis  in  children,  his  conclusions  bein.i^ 
based  on  54  cases  of  tubercular  peritonitis  in  children  under  thir- 
teen years  of  ag'e : 

(  i)  Tubercular  peritonitis  is  more  conmion  in  children  than 
is  usually  suppa^ed. 

(2)  It  can  be  laid  down  as  a  general  rule  that  all  cases  of 
so-called  spontaneous  ascites  are  really  due  to  tubercular  per- 
itonitis. 

(3)  Not  infrequently  the  exudate  of  the  peritoneal  cavity 
will  disappear  under  general  tonic  treatment  and  the  child  will 
regain  complete  health. 

(4)  In  the  majority  of  cases  the  onset  of  the  disease  is 
imperce])tible.  The  parents  first  notice  that  the  child  becomes 
pale  and  thin,  without  apparent  cause. 

(5)  The  presence  of  coincident  serous  pleurisy  is  stroni^ 
coiifiniiafory  c-i'idciicc  in  the  diagnosis. 

(6)  Thickening  of  the  parietal  peritoneum  is  the  most 
valuable  sign  in  the  diagnosis.  This  sign  can  be  readily  elicited 
before  adhesions  have  formed,  by  picking  up  a  fold  of  the  anterior 
abdominal  wall  and  palpating  the  peritoneum  between  the  thumb 
and  fingers,  provided  the  examiner  is  accustomed  to  the  palpation 
of  the  normal  peritoneum. 

(7)  In  exudative  tubercular  peritonitis,  the  fluid  obtained 
by  tapping  is  very  rich  in  albumen  and  has  a  high  specific  gravity. 

(8)  In  many  patients  who  present  no  subjective  symptoms, 
the  whole  peritoneum  is  found  covered  with  a  thick  layer  of 
tubercular  masses. 

(9)  Chronic  ascites,  due  to  tubercular  pericarditis,  aflfords 
the  greatest  difficulties  in  difTerential  diagnosis,  but  this  condition 
is  very  rarely  seen. 

(To)  Only  in  severe  cases  does  tuliercular  peritonitis  have 
a  severe  onset. — Earle.] 

TUMORS  OF  TIJE   AllDOMEX. 

The  diagnosis  of  a  tumor  of  the  abdomen  nuist  alwavs  be 


*Archk:  f.  Kliiiischc  Cliinirgic.  Bd.  65,  Hft.  2  (quoted  from  I'lie  Prac- 
tical Med.  Series  of  Year  Hooks,  Vo'.  MT..  Pediatrics,  ed.  Iiy  I.  .\I)t, 
p.  62). 


232  SEMEIOLOGV   OF   THE   EXLARC.ED   ABDOMEN 

preceded  by  determining  in  which  organ  it  arises  and  then  later 
its  nature  may  be  distinguished. 

Enlargement  of  the  liver  an.d  spleen  are  at  once  recognized 
bv  the  place  the  tumor  occupies  and  its  form,  while  especially 
characteristic  is  the  fissure  on  the  lower  margin  of  the  liver  or  on 
the  anterior  margin  of  the  spleen. 

About  tumors  in  the  liver  we  shall  say  but  a  few  words,  ?.s 
tlie\   manifest  themselves  by  the  same  symptoms  as  in  adults. 

The  liver  in  children  of  the  first  years  of  life,  and  in  normal 
condition,  extends  one  or  two  inches  from  the  ribs  on  the  mam- 
millary  line,  and  if  it  cannot  be  palpated  it  is  only  because  its 
margin  is  not  hard  enough.  But  as  soon  as  the  liver  becomes 
somewhat  harder  it  immediately  becomes  easily  palpa1)le  and  seems 
to  be  enlarged. 

In  some  cases  the  surface  of  the  enlarged  liver  appears  even 
and  smooth,  in  others  uneven,  nodular.  Sometimes  it  is  consider- 
ably enlarged ;  sometimes,  however,  it  remains  almost  normal.  In 
view  of  these  symptoms,  and  especially  ^etiological  factors,  the 
diagnosis  of  hepatic  swelling  is  usually  not  difficult. 

Ac}itc  moderate  enlargement  of  the  liver,  with  smooth  sur- 
face and  moderate  hardness,  occurs  in  children,  first,  from  stasis 
of  the  bile  during  catarrhal  jaundice;  and,  second,  from  parenchy- 
niaious  sivelling  or  hyi)eraemia  of  the  liver  during  acute  infectious 
diseases,  for  instance,  typhoid,  relapsing  fever,  etc.  In  both  these 
conditions  the  enlargement  disappears  soon  after  the  causative 
disease  has  been  cured. 

Here  may  also  be  included  hyperjemic  tumor  of  the  liver 
caused  by  poisoning,  for  instance,  by  phosphorus. 

In  chronic  cases  a  large  li:'er  with  a  smooth  surface  and  but 
little  pain,  or  altogether  painless  upon  pressnre,  may  depend  upon 
the  following  causes : 

(1)  Passive  iivperaemia  of  the  liver  occurs  in  cardiac 
lesions,  chronic  pleurisy  and,  in  general,  in  conditions  which 
hinder  the  return  of  venous  blood  to  the  heart.  The  liver  is  some- 
what tender  or  even  painful  upon  pressure,  extends  from  under 
the  ribs  on  the  mammillary  line  a  distance  of  two  or  three  fingers' 
breadth  in  slight  cases,  and  in  severer  ones  descends  below  the 
navel,  the  hardness  being  very  great.  The  size  of  the  organ  de- 
creases as  soon  as  the  cardiac  actiiity  increases. 


SE^^l^I()L()^,^    ov  'iiik  enlauci-:!)  ap.do.men  233 

The  diagnosis  of  staoiuml  hy]jcra;niia  of  the  liver  cannot  be 
^iiade  if  there  are  no  astiological  conditions,  as  cardiac  weakness 
or  some  other  obstacle  to  the  blood  circulation.  A  stagnant  liver 
may  sometimes  be  observed  during  scarlatinal  nephritis  associated 
with  a  dilated  heart  and  its  consequent  failure. 

(2)  Interstitial  hepatitis  usually  occurs  1)ecause  of  an 
old  intermittent  of  long  duration.  The  liver  is  very  hard  and  pain- 
less upon  pressure.  A  large  and  hard  spleen  is  also  always  pres- 
ent. Obolensky's*  observations  show  that  such  hypertrophic  cir- 
rhosis is  capable,  under  the  influence  of  calomel  treatment,  of  un- 
dergoing retrograde  metamorphosis,  and  together  with  the  de- 
crease of  the  size  of  the  liver  the  general  condition  of  the  ]')atient 
also  improves. 

(3)  Fatty  liver  in  children  does  not  reach  very  great  size 
and  hardness,  its  surface  being  entirely  smooth.  It  occurs  in 
nurslings,  in  fat  children  under  the  influence  of  superfluous  milk, 
as  well  as  in  exhausted  patients,  especially  in  tuberculosis,  anaemia 
-and  rachitis. 

From  the  amyloid  liver  which  also  occurs  sometimes  in 
tubercular  and  exhausted  children,  the  fatty  liver  difl:'ers  prom- 
inently b}'  its  soft  consistency  and  smaller  size  ( never  reaches  the 
navel).  In  cloudy  swelling  the  liver  is  also  but  slightly  enlarged, 
soft  and  smooth,  but  the  aetiology  is  here  quite  different,  as  granu- 
lar degeneration  or  cloudy  swelling  occurs  during  acute  febrile 
■diseases  and  develops  acutely. 

(4)  Amyloid  li\'er  (was  discussed  on  page  22t,). 

(5)  Leuk.T£MIC  liver  is  in  size  and  hardness  quite  equal 
to  the  preceding  form,  being  also  accompanied,  like  the  former, 
"by  considerable  swelling  of  the  spleen,  difl^'ering,  however,  by  be- 
ing associated  with  svmptoms  of  leuktcmia  (examination  of  the 
blood),  while  the  ^etiological  factors  peculiar  to  amyloid  liver  are 
absent. 

(6)  EcHiNOCOccus  OF  the  liner  also  causes  considerable 
enlargement  and  hardness  of  the  organ,  but  dififcrs  from  all  other 
similar  processes  by  its  very  slow  course  (several  years),  and 
■still  more  by  the  general  condition  remaining  very  good  even  when 
the  liver  becomes  immense,  reaching,  for  instance,  to  the  navel. 


*Mc(Iic.  Obocr.  1.  XXX..  page  254. 


234  si-:mf.iolugy  of  the  exlak(ji:i)  auuumen 

Such  an  al)sence  of  correspondence  between  the  fi^ood  condition  of 
the  general  nutrition  on  the  one  hand  and  the  immense  Hver  on 
the  other,  in  connection  with  the  very  slow  course,  absence  of 
ascites  and  jaundice,  makes  the  diai^nosis  of  echinococcus  very 
probable,  even  when  the  symptoms  do  not  point  especially  to- 
echinococcus.  However,  this  rule  admits  of  some  exceptions.  As^ 
for  instance,  during-  the  fall,  1897,  a  girl  five  years  old  entered 
our  clinic  on  account  of  a  large  abdomen.  The  mother  claimed 
that  the  enlargement  of  the  abdomen  was  noticed  three  years  be- 
fore. The  patient  had  a  gfxid  general  nutrition,  l)ut  was  pale;, 
was  up  during  the  whole  day  and  made  no  complaint.  The  ob- 
jective examination  detected  only  niu'  abnormalit} ,  namely,  a 
large  liver;  its  lower  margin  reached  the  navel  in  the  median  line^ 
on  the  anterior  right  axillary  line  it  almost  reached  the  iliac  bone. 
The  induration  was  not  great,  its  surface  was  entirely  smooth;, 
ascites  was  absent,  as  well  as  jaundice.  In  brief,  everything^ 
seemed  to  indicate  echinococcus,  and  the  ])atient  was  therefore 
transferred  to  the  surgical  clinic.  Professor  llobroff  performed 
an  ex])]()rat()ry  la])ari)i()my.  ex])()sed  the  li\er,  examined  the  same 
by  palpation  and  puncture  with  a  needle,  but  found  nothing  be- 
yond the  considerable  hy])ertroi)hy  of  the  organ.  The  wound 
was  closed  and  ihe  girl  left  the  hospital  in  the  same  condition 
as  before. 

In  January,  1F98,  another  girl  enterel  the  clinic  on  account 
of  ])neumonia.  The  examination  of  the  jiatient  detected  the  same 
kind  of  liver  as  in  the  preceding  case,  that  is,  ecjually  big.  smooth 
and  not  very  solid,  leading  to  a  diagnosis  not  of  echinococcus  of 
the  liver,  but  of  simple  hypertrophy. 

In  view  of  such  possibilities  one  must  be  very  careful  in  his- 
judgment  until  special  symptoms  of  echinococcus  appear  ;  these 
symptoms  occur  when  the  echinococcus  cyst  is  located  on  the 
upper  surface  of  the  liver,  accessible  to  ]:)al]iation.  Then  one  may 
easily  feel  on  the  free  surface  of  the  liver  a  smooth,  half-spherical 
convexity,  which  fluctuates  more  or  less  noticeably.  The  fluid 
drawn  through  an  exploratorv  puncture  from  this  convexity  dif- 
fers from  any  transudate  or  exudate  in  not  containing  albumen, 
but  being  very  rich  with  sodium  chloride,  lender  the  microscope 
it  is  sometimes  possible  to  detect  the  booklets  of  echinococcus. 

If  the  cyst  of  the  parasite  is  located  near  the  portal  fissure,. 


SEMEIOLUGV    OF    Til!'-.    i:X  I..\KC,l-:i )    A  111 )( ).M  i:.\  j  ^5 

and  by  compressing-  the  vena  porta  or  the  gall  bladder  pro<hices 
ascites  or  jaundice,  then  the  diagnosis  is  more  difficult. 

Echinococcus  multilocularis  of  the  liver  produces  an  entirely- 
different  clinical  picture,  but  in  childhood  such  a  form  has  not 
been  described. 

In  abscess  of  the  liver,  which  is  usually  of  pyemic  origin,  the 
organ  also  considerably  enlarges  and  tluctuating  tumors  may  be 
palpated  on  its  surface.  lint  then  there  is  always  irregular  fever, 
the  liver  is  painful  and  the  general  condition  severely  suffers. 
Sometimes,  but  in  very  rare  cases,  the  margin  of  the  liver  may 
be  palpated  near  the  navel,  not  becatise  this  organ  is  enlarged, 
but  ])ecause  it  is  displaced. 

Displacement  of  the  liver  downwards  is  most  often  observed 
in  children  during  an  abundant  right-sided  pleuritic  exudation, 
which  is  to  be  detected  by  an  examination  of  the  chest.  In  other 
cases,  as,  for  instance,  in  Goundobin's  reports*  the  dislocation 
of  the  liver  depends  plainly  upon  weakening  of  the  suspensory 
ligament.  Such  a  displacement  of  the  liver  differs  from  its  en- 
largement by  the  lowering  of  the  upper  margin  of  the  organ, 
which  may  be  readily  recognized  by  percussion. 

A  LARGE  I.IVER  WITH  AN  UNEVEN,  THAT  IS,  NODULAR  SUR- 
FACE, occurs  in  syphilis  and  in  malignant  new  growths  of  this 
organ. 

Syphilis  of  the  liver  was  referred  to  on  page  222.  Besides  the 
gunmious  form  of  syphilis,  there  also  occurs  in  children  diffuse 
interstitial  syphilitic  hepatitis,  in  which  the  liver  increases  in  its 
size  and  preserves  its  smooth  surface.  However,  this  form  being 
peculiar  to  new-born  and  nurslings,  in  a  later  age  is  almost  never 
observed. 

^Talignant  tumors  of  the  liver  in  children  very  seldom  occur 
])rimarily  ;  usually  the  liver  becomes  aft'ected  secondarily  in  in- 
stances of  sarcoma  of  the  eye,  kidne\s,  or  bones.  The  patient 
soon  becomes  cachectic  and  lives  not  more  than  three  or  four 
months.  The  symptoms  pertain  to  an  immense  nodular  enlarge- 
ment of  the  liver. 

Enlargement  of  the  spleen  occurs  in  children  very  often 


'Mcdiciiiskoic   ()bo::rciiic.  XXIX.,  page  650. 


236  SEMEinLOGV    OF   THE   ENLARGED   ACDf)ME> 

in  acute  as  well  as  m  the  chronic  iovm.     Tumor  of  the  spleen 
mav  he  recognized  by  percussion  and  palpation. 

Xormally  the  upper  boundary  of  dullness  of  the  spleen  begins 
at  the  posterior  axillary  line  (where  the  spleen  extends  from  under 
the  lung)  from  the  ninth  rib.  The  anterior  boundary,  corre- 
sponding to  the  anterior  margin  of  the  spleen,  lies  on  the  middle 
axillary  line  or  passes  somewhat  beyond  the  same,  but  never 
reaches  the  line  which  connects  the  left  nipple  with  the  end  of 
the  eleventh  rib;  the  lower  end  of  dullness  (the  lower  border 
of  the  spleen)  lies  on  the  posterior  axillary  line  near  the  lower 
end  of  the  ribs  and  somewhat  backwards  from  the  end  of  the 
eleventh  rib,  which  usually  lies  on  the  middle  axillari  line.'' 
Therefore,  the  dull  note  of  the  spleen  may  be  held  as  increased  if 
the  same  begins,  on  the  posterior  axillary  line,  higher  than  the 
ninth  rib  and  reaches  the  eleventh,  and  if  its  anterior  mar- 
gin reaches  or  passes  beyo)id  the  line  connecting  the  end  of 
the  clcvoith  rib  icith  the  nipple. 

I  hrancesco  Sarcinelli  describes  a  new  method  of  percussing 
the  spleen  in  children.  He  finds  that  the  ordinary  method  defines 
only  that  portion  of  the  spleen  which  is  uncovered  by  lung,  so  he 
has  the  child  suspended  in  a  position  midway  between  the  dorsal" 
decubitus  and  the  left  lateral  position,  one  arm  of  the  attendant 
being  placed  under  the  child's  left  shoulder,  the  other  under  the 
pelvis.  This  permits  the  spleen  to  sink  by  the  force  of  gravity 
toward  the  abdominal  parietes.  Percussion  should  be  performed 
from  below  upward.** — Eaklk. J 

But  the  results  of  percussion  are  to  be  regarded  as  indicative 
only  in  case  the  same  result  is  obtained  for  two  or  three  days  in 
succession,  because  in  the  contrary  event  one  cannot  be  sure  that 
the  increase  of  splenic  dullness  does  not  depend  upon  accumula- 
tion of  fseces  in  the  neighboring  mtestinal  coils,  and,  vice  versa, 
an  enlarged  spleen  may  give  a  normal  area  of  splenic  dullness  cov- 
ered with  intestines  inflated  with  gases. 

Much  more  certain  results  are  obtained  by  means  of  palpat- 
ing. The  younger  the  child  the  easier  the  spleen  may  be  palpated 
when  it  is  enlarged.  In  children  of  the  first  months  of  life  it 
may  occasionally  be  palpated  even  in  normal  condition.     Exclud- 

*Sahli:  Die  topograph.    Pcrcus.  im  Kiiidcsaltcr,  1882,  S.   155. 
**QrLOted  irom.-i)iicricaii  Yrar-Boole  of  Mcdicuic.  1904.  p.  282. 


SE.Ml'.loi.dclV    OF    llll-:    KXLARCED   AUDI  )Ml-:x  23/ 

ing  these  cases,  it  may  be  accepted  as  a  rule  that  //  the  spleen  is 
palpable  it  means  that  it  is  enlarged  (unless  it  is  displaced  by  a 
left-sided  pleuritic  exudation). 

To  distini^uish  an  acute  swelling  of  the  spleen  from  a  chronic 
one  is  not  always  easy  at  the  first  examination  of  the  patient.  In 
chronic  enlargement  the  spleen  is  in  general  harder  and  larger. 
In  acute  swelling  the  spleen  seldom  extends  from  under  the  ribs 
more  than  two  or  three  fingers'  breadth.  If  the  swelling  of  the 
spleen  is  observed  in  a  patient  who  is  not  suffering  from  any 
febrile  disease,  then  it  is,  of  course,  a  chronic  occurrence.  How- 
ever, if  the  patient  has  high  fever  we  may  look  upon  the  splenic 
tumor  as  of  recent  origin  only  if  it  developed  under  our  observa- 
tion, or  if  it  is  known  that  a  few  days  or  weeks  before  the  patient 
had  no  swelling  of  the  spleen.  A  recent  tumor  of  the  spleen 
may  be  suspected  then  if  the  same,  being  inconsiderably  enlarged, 
is  painful  upon  palpation. 

It  is  important  to  determine  the  existence  of  an  acute  splenic 
tumor,  because  upon  that  the  diagnosis  of  a  given  febrile  disease 
may  depend,  as  it  is  known  that  swelling  of  the  spleen  is  not  the 
same  in  each  febrile  disease,  even  in  an  infectious  one.  Acute 
spleen  tumor  most  often  occurs  in  all  kinds  of  t}-phoid,  in  malaria 
and  in  pysemia. 

Of  special  importance  is  a  recent  swelling  of  the  spleen  in  the 
diagnosis  of  typhoid  when  the  latter  must  be  differentiated  in  the 
first  days  of  disease  from  dilTerent  fevers  due  to  cold  or  gastric 
troubles,  as  well  as  from  son.ie  cases  of  meningitis  which  may 
be  very  similar  to  typhoid  in  the  course  of  the  temperature  and 
some  other  symptoms. 

The  presence  of  the  splenic  tumor  in  different  other  febrile 
diseases  cannot  diminish  the  diagnostic  importance  of  this  symp- 
tom, because  all  diseases  which  may  be  associated  with  tumor 
of  the  spleeu  have  in  the  majority  of  cases  almost  nothing  to  do 
with  typhoid,  so  that  they  may  be  easily  distinguished  from  it 
aside  from  the  splenic  symptoms.  It  would  be  illogical,  for  in- 
stance, to  diagnose  typhoid  on  the  ground  of  the  spleen  tumor, 
if  the  patient's  skin  was  covered  with  a  scarlatinal  or  smallpox 
eruption,  or  if  there  were  definite  symptoms  of  croupous  pneu- 
monia. 

CiiRoxic  SPLEEN  TL'MOR  in  children  under  two  years  of  age 


238  SEMEIOLOGV   OF   THE   ENLARGED   ABDOMEX 

occurs  most  often  in  rachitis,  but  also  in  inherited  syphilis.  Tn 
both  these  diseases  the  spleen  sometimes  reaches  a  considerable 
size  (extending  three  or  four  fingers'  breadth  beyond  the  ribs), 
and  is  very  hard  (hyperplasia  of  the  connective  tissue).  Such 
children  usually  exhibit  an  advanced  anaemia  (waxy  pallor)  and 
not  infrequently  enlarged,  hard  liver ;  in  short,  the  aspect  of  the 
disease  very  much  resembles  leukaemia  or  amyloid  spleen  and  liver. 

The  absence  of  an  increased  number  of  white  corpuscles  dis- 
tinguishes these  cases  of  chronic  hypertrophy  of  the  spleen  from 
a  leukaemia,  and  the  termination  with  recovery,  from  pseudo- 
leukaemia.  Regarding,  however,  an  amyloid  spleen  the  diagnosis 
is  based  mainly  on  the  aetiology.  In  amyloid  degeneration  there  is 
the  presence  of  chronic  suppuration  somewhere  in  the  body 
(caries,  pulmonary  tuberculosis,  etc.).  It  is  true  that  chronic 
tumor  of  the  spleen,  together  with  considerable  anaemia,  sometimes 
occurs  in  children  apparently  healthy  in  all  other  regards,  that  is, 
in  such  as  have  neither  rachitis  or  s)philis.  Such  examples  are 
described  as  infantile  splenic  anccmia — ancemia  splenica  infantum. 

In  older  children  large  and  hard  spleens  are  most  often  the 
sequelae  of  a  protracted  intermittent  fever ;  less  frequent  of  an 
amyloid  degeneration,  leukaemia  or  pseudo-leukaemia. 

The  diagnosis  of  the  causes  of  the  spleen  tumor  is  based  on 
the  history  and  symptoms  which  are  peculiar  to  this  or  that 
disease. 

The  kiihiex  may  be  palpated  as  a  tumor  in  the  abdomen  when 
too  movable — movable  kidney,  or  if  considerably  enlarged. 

A  movable  kidney  which  simulates  a  tumor  in  the  abdomen 
may  be  recognized,  first,  by  its  size  and  shape;  second,  by  the 
possibility  of  being  pushed  to  its  former  place.  Also  character- 
istic of  the  great  mobility  of  the  tumor:  today  it  may  be  found 
near  the  navel,  on  the  next  day  it  cannot  be  found  at  all,  etc. 

[In  Abt's  cases  the  kidney  descended  into  the  pelvis  on  the 
right  side  or  even  crossed  over  and  lodged  in  the  pelvis  of  the 
opposite  side  (during  forced  movements,  running  or  jumping). 
These  distant  excursions  caused  severe  pains,  which  the  patient 
learned  to  relieve  by  grasping  the  organ  and  pushing  it  up  in 
place. '^•' — Earle.  ] 

*Joui:  Am.  Med.  Ass'n.,  Sept.  28.  1901. 


SEMKlOlcCN     OF    llTl-    ['.M  ..\K(  ,i:i)    A  HI  )().\I  KX  2^0 

Tumors  of  tiii'.  kidnkvs,  due  to  the  presence  of  nialignav.t 
iiezv-grozutlis  in  them,  are,  indeed,  of  great  rarity,  nevertheless 
sarcoma  and  carcinoma  of  the  kidneys  are  exclusively  diseases  of 
childhood,  and  it  is  especially  noteworthy  that  the  maximum 
incidence  of  these  diseases  coincides  with  the  age  under  five  years. 
(According-  to  Epstein,  of  fifty-two  cases  of  primary  carcinoma 
-of  the  kidneys  it  was  found  in  children  from  birth  up  to  five  vears 
•old  in  sixteen  cases  ;  while  in  adults  from  forty  to  fifty  in  six 
cases;  from  fifty  to  sixty  in  ten  cases.)* 

Of  all  internal  organs  the  kidneys  and  the  suprarenal  glands 
l:)ecome  aitected  with  carcinoma  most  frequently.  This  fact  being 
very  important  in  the  diagnosis,  because,  if  the  physician  has  some 
reason  to  make  a  diagnosis  of  a  malignant  new-growth  in  the 
abdominal  organs,  then  he  may,  a  priori,  suppose  that  the  kidneys 
are  primarily  affected  in  the  child,  or,  which  is  more  correct,  one 
"kidney   bilateral  carcinoma  of  the  kidneys  occurring  very  rarely. 

In  the  first  stage  of  formation  of  cancer  the  patient  usually 
does  not  complain  of  anything,  but  at  times  there  appear  haema- 
turia  or  albuminuria ;  but  both  of  these  symptoms  may,  however, 
be  absent.  Later  on  a  tumor  appears  in  the  lumbar  region,  pal- 
pated most  readily  in  the  lateral  part  of  the  abdomen  between  the 
iliac  crest  and  the  lower  boundary  of  the  ribs. 

The  enlargement  of  the  kidney  occurs  rapidly,  being  ac- 
•companied  by  considerable  pain  in  the  abdomen  and  the  rapid 
development  of  cachexia.  If  the  size  of  the  tumor  becomes  such 
that  it  may  be  easily  palpated  through  the  anterior  abdominal 
wall,  then  it  generally  presents  the  following  peculiarities :  It 
is  immovable  (during  respiration  as  well  as  in  passive  move- 
ments) ;  its  upper  boundary  may  be  easily  palpated  and  it  will  be 
thus  observed  that  the  tumor  does  not  arise  from  the  liver.  It 
■grows  from  behind  forwards,  displacing  the  bowels  to  the  side, 
and  as  the  colon,  being  attached  by  a  friable  cellular  tissue  to  the 
■quadratus  lumborum,  does  not  follow  the  general  displacement  of 
the  bowels,  it  remains  over  the  anterior  surface  of  the  tumor ; 
it  may  be  recognized  by  the  path  of  tympanitic  sound  which  ex- 
tends in  an  oblique  direction  from  the  lower  end  of  the  tumor  to 
its  upper  end.     The  surface  of  the  tumor  is  nodular;  the  consist - 


^Ziciiisscii's  Haiuibncli.  IX  B.  S.  112. 


240  SEMEIOLOGY   OF   THE   ENLARGED   ABDOMEN 

enc}'  disproportionate.  The  abdomen  is  much  distended,  but 
ascites  may  be  absent  if  the  new  growth  has  not  involved  the 
peritoneum.  In  the  event  of  subsequent  affection  of  the  mesen- 
teric and  retroperitoneal  glands,  tumors  of  different  size  and  sol- 
idity may  also  be  palpated  in  different  locations  in  the  abdomen ; 
but  the  chief  tumor,  which  corresponds  to  the  kidney,  will  be  felt 
only  between  the  crest  of  the  ilium  and  the  false  ribs,  thence  it 
may  be  traced  backwards  to  the  lumbar  region  and  forwards  ta 
the  navel.  For  the  sake  of  better  determining  the  boundaries  of 
such  a  tuuK^r  the  examination  should  always  be  conducted  with 
both  hands  ;  one  exercising  pressure  over  the  tumor  on  the  side 
of  the  abdomen,  the  other  placed  over  the  lumbar  region. 

An  immense  abdomen,  painful  in  some  parts  thereof,  and  the 
presence  of  tumors  of  varying  size  and  firmness,  gives  the  im- 
pression of  a  disease  due  either  to  renal  cancer  or  to  that  of 
chronic  peritonitis. 

The  diagnosis  is  based  on  the  more  rapid  development  of 
cachexia  during  carcinoma  (fatal  termination  occurs  in  three  or 
four  months,  in  tubercular  peritonitis  in  about  six  to  twelve 
months)  ;  on  the  form,  size  and  situation  of  the  tumors  (in  per- 
itonitis the  tumors  are  most  often  palpated  between  the  navel  and 
epigastrium ;  on  percussion  they  give  a  tympanitic  note,  because 
the  limited  thickness  of  the  inflammatory  infiltrations  cannot 
deaden  the  tympanitic  sound  of  the  bowels)  ;  on  the  absence  of 
ascites  during  carcinoma,  and  tuberculosis  of  other  organs. 

On  the  contrary,  normal  urine,  free  from  albumen  and  bloody 
cannot  serve  as  evidence  against  carcinoma  of  the  kidney,  because 
albuminuria  and  h?ematuria  may  be  observed  only  during  such 
time  as  the  affected  kidney  continues  its  physiological  function. 

In  children  still  another  variety  of  tumor  of  the  kidney  oc- 
curs, which  sometimes  reaches  immense  dimensions,  namely^ 
HYDRONEPHROSIS.  In  the  abdomen  a  spherical,  fluctuating,, 
smooth  growth,  connected  with  the  kidney,  may  be  palpated.  A 
transparent  fluid  containing  urea  and  uric  acid  may  be  drawn 
therefrom  by  an  exploratory  puncture.  A  similar  fluctuating^ 
tumor  may  also  be  met  with  in  echinococcus  of  the  kidney  and  in 
ovarian  cyst,  but  both  are  extremely  rare.  However,  cases  of 
successfully  operated  ovarian  cysts  have  been  described  in  girls- 
nine  or  ten  vears  old. 


SEMEIOLOGV    Ol"     I  1 1  K    i:.\  I.ARC.i:! )    A  111 )(  )M  1-:N  J4  I 

If  a  thictuatin^-  tunior  arising  from  the  kiclnc)  depends  upon 
echinococcus,  then  in  the  aspirated  fluid  there  can  he  demonstrated 
neither  constituents  of  urine,  nor  alhtnnen,  hut  hooklets  of  echin- 
ococcus will  be  found  under  the  microsco])e. 

In  large  ovarian  cysts  the  tumor  is  also  spherical,  smojth  and 
fluctuating,  but  it  arises  in  the  false  pelvis  occupying  the  umbilical 
area  and  the  hypogastrium  ;  the  lateral  parts  of  the  back  remaining 
free.  On  percussion  a  clear  sound  may  be  obtained,  depending 
upon  whether  the  patient  lies  on  the  back  or  on  the  side.  The 
absence  of  fluctuation  does  not  exclude  ovarian  cysts,  because  this 
symptom  may  be  incapable  of  detection  by  diverse  circumstances, 
as  ninltilixnilar  c}-sts,  thick  walls  and  dense  contents. 

\  oluminous  tumors  of  the  abdomen  may  be  produced  by 
cascoHS  degeneration  of  the  mesenterie  glands,  or  by  sarcoma  of 
the  retro-peritoneal  glaiids.  In  the  former  case  a  nodular  growth 
is  palpated  in  the  umbilical  region,  unless  this  be  prevented  by  a 
considerable  meteorism,  which,  unfortunately,  almost  always  oc- 
curs in  such  patients,  thus  making  the  enlarged  mesenteric  glands 
inaccessible. 

Sarcomatous  degenerated  retro-peritoneal  glands  which  lie 
forwards  and  on  the  sides  of  the  lumlxir  portion  of  the  vertebral 
column  are  more  often  accessible  to  palpation. 

An  irregular  tumor,  sometimes  of  great  dimensions,  usually 
ma}-  be  felt  in  the  lower  portion  of  the  abdomen,  or  in  its  lateral 
portions  between  the  iliac  crest  and  the  false  ribs.  In  the  latter 
case  the  tumor  may  be  mistaken  for  sarcoma  of  the  kidney. 

The  difl:'erentiation  is  based  partly  on  the  analysis  of  the 
urine  (in  affection  of  the  retro-peritoneal  glands  the  urine  is 
normal,  in  carcinoma  of  the  kidneys  it  not  infrequently  contains 
albumen  and  blood)  ;  and  partly  on  the  position  of  the  tumor 
regarding  the  vertebral  column  ( the  lym])hatic  glands  are  located 
in  the  middle  line,  the  kidneys  laterally). 

We  have  already  mentioned  the  possibility  of  palpating 
tumors  due  to  formation  of  inflammatory  infiltrations  during 
chronic  peritonitis  and  perityphlitis,  or  sausage-like  tumors  dur- 
ing intestinal  intussusception.  It  remains  here  only  to  mention 
tumors  caused  b}'  the  accmuulation  of  f;cces  in  the  large  bowels, 
and  the  suprapubic,  elastic  tumor  due  to  the  distension  of  the  blad- 
der with  urine. 


242  SEMEIOLOGV    OF   THE   ENLARGED   ABDOMEN 

Faecal  tumors  are  felt  either  in  the  middle,  or  in  the  lateral, 
portions  of  the  abdomen ;  they  are  movable  and  painless.  Their 
most  characteristic  feature  is  disappearance  after  a  laxative. 

The  young  physician  must  bear  in  mind  that  in  the  epigastric 
region  between  the  navel  and  the  pit  of  the  stomach,  somewhat 
aside  from  the  median  line,  a  quite  solid  tumor  may  be  felt  caused 
by  the  contraction  of  the  upper  belly  of  the  rectus  abdominis. 
This  false  tumor  differs  from  a  real  one,  first,  by  its  being  in- 
constant, and,  second,  by  its  outline  corresponding  to  the  boun- 
daries of  the  muscle. 

In  conclusion  we  would  remark  that  tumor  in  the  iliac  region 
may  depend  upon  accumulation  of  pus  at  this  point,  for  instance 
in  psoitis  or  in  abscesses  following  vertebral  caries. 


INTESTINAL  WORMS. 

In  the  lx)\vels  of  children  several  kinds  of  round  and  flat 
Avorms  are  to  be  found.  Of  the  class  of  round  worms  of  clinical 
interest  may  be  named  oxyiiris  zrniiicularis  and  ascaris  lunibri- 
■coides,  of  tlie  tapeworms,  tcciiia  soliiiiii,  tcoiia  mediocaiiellata, 
bothrioccplialns  latiis.  tcciiia  ciicuiiicriiia,  s.  elliptica  and  tcciiia 
nana. 

[Intestinal  worms  are  observed  less  frequentl}-  in  America 
than  in  Europe.  Holt  in  10,000  patients  treated  for  medical  dis- 
eases, in  dispensary  service,  found  positive  evidence  of  worms  in 


Fig.  18 — Oxyuris  vermicularis   (natural  size). 

but  79  cases.  Of  these  nine  had  tapeworms,  forty  roundw^orms, 
twenty-seven  threadworms,  and  three  both  round  and  thread- 
Avorms.* — Earle.  J 

Oxyuris  vermicularis  is  the  smallest  of  all  intestinal  worms 
(about  half  a  centimeter  in  length.)  (Fig.  18.)  This  worm  lives 
particularly  in  the  large  bowels  and  sometimes,  especially  at  even- 
ing, is  expelled  from  the  rectum,  causing  severe  itching  at  the 
anus.  If  the  patient  be  examined  at  this  time  then  the  cause  of 
the  itching  will  be  readily  detected  by  the  presence  of  several 
worms  around  the  anus  and  its  folds.  They  may  also  be  found  in 
the  dejections  as  very  small,  movable,  white  worms.  At  any  rate 
the  night,  or  evening,  itching  is  of  itself  so  characteristic  of  this 
worm  that  a  correct  diagnosis  may  be  made  even  without  examin- 


*Holt:  The  Diseases  of  Infancy  and  Childhood.    1902,  p.  441. 


244  INTESTINAL    WORMS 

ing  the  faeces.  If  a  physician  ijTnores  the  indication  of  oxvuris 
vermicularis,  ascribing  the  periodically  occnrring  evening  itching 
to  a  masked  fever,  he  would  act  very  rashlv. 

[Rammsted,  Shiller  think  that  one  should  examine  the  stools 
for  the  presence  of  this  worm  in  each  case  of  appendicitis,  as  they 
have  seen  cases  of  the  latter  due  to  oxyuris  vermicularis.*     Erd- 


Fig.  19 — Eggs  of  oxyuris  \erniicularis. 

man  also  reported  two  cases  of  appendicitis  in  which  the  appendix 
was  found  to  contain  numerous  i:)in- worms  (oxyuris  vermicular- 
is).-^^* — Earle.] 

The  eggs  of  the  oxyuris  vermicularis  are  of  irregular,  oval 
form  wth  contents  of  equal  granularity  (Fig.  19}. 

AscARis  ltjMBRIcoides  is  in  shape  quite  similar  to  a  dew- 
worm,  but  differs  from  the  latter  by  its  greater  size  (about  four 
and  a  half  inches  in  length)  and  whitish  color  with  a  rose  tint. 
The  eggs  are  recognized  by  the  nodular  shell  (h^ig.  20). 

To  the  group  of  round  worms  also  belongs  the  trichocephalus 
dispar  (Fig.  21).  which  usually  lives  in  the  caecum  and  is  charac- 
terized by  the  hair-like  anterior  part,  the  posterior  being  much 
thicker.  Its  eggs  are  oval  in  shape  and  decidedly  differ  from  the 
eggs  of  all  other  kinds  of  intestinal  worms  by  having  marked 
thickening  at  both  poles.     (Fig.  22.) 


*Deuf.  Med.  Wochcnschr.,  December  18.  1902. 
**Archiz'cs  of  Pediatrics.  June,  1903. 


INTESllXAI.    WORMS 


245 


All  tapewotms  are  similar  to  each  other  by  consistinj:^  of 
segments  connected  in  a  chain.  Ihe  nearer  to  the  head  the  smaller 
the  seg'ments  become,  so  that  in  tlie  lliiimest  portion  of  the  tape- 
worm, in  the  so-called  neck,  which  looks  like  a  thread,  thev  are 
not  to  be  distinguished  at  all  by  the  naked  e\e. 

The  smallest  variety  of  tapeworm  is  tccnla  nana.  This  worm 
is  seldom  seen  in  Europe  ( it  occurs  especially  in  Egypt  and  south- 


Fig.   20 — Ascaris   lumbricoides.  and   the  egg   of  this   worm. 

ern  Ital}).  Up  to  the  year  1901  oidy  one  case  of  this  worm  was 
described  in  Russia,  by  Prof.  Aphanassief¥,  of  St.  Petersburg. 
This  was  in  a  young  soldier.  Examination  of  f?eces  in  our  clinic 
has  determined,  however,  that  tsenia  nana  occurs  in  Moscow  not 
ver\-  rarely.  During  the  last  spring  we  observed  three  cases  of  this 
worm,  in  a  boy  eight  years  old,  and  his  six-year-old  sister,  and 
then  in  a  girl  one  year  and  three  months  of  age,  who  died  from 
laryngo-spasm. 

Despite  the  fact  that  this  worm  inhabits  the  bowels  usually 
in  great  numbers  (a  cou]ile  of  hundred),  yet  to  find  it  in  the  evac- 
uations   is   a   ver\-   diflictilt    matter,   because   it    is   verv   thin   and 


246 


INTESTINAL    WORMS 


small.  An  examination  may  be  made  in  the  following  way :  Take 
on  the  tip  of  a  flat  knife  the  fluid  contents  of  the  intestines  and 
place  them  in  a  plate  with  water.  The  heavier  dejections  rapidly 
sink  to  the  bottom  after  shaking,  and  the  worms  being  lighter 
remain  for  some  time  suspended  in  the  water,  so  that  it  is  easy  to 
notice  and  remove  them. 

The  length  of  the  worm  is  from  one  to  two  centimeters,  the 


Fig.  21 — Trichocephalus  dispar   (afler  Leuckart  )    (a)   male,    (b)    female — 
natural    size   and   magnified. 

breadth  0.5  to  i  m.m.     The  head  is  armed,  as  in  taenia,  by  four 
suckers,  a  circle  of  hooks  and  a  beak.     The  segments  are  as  in. 


Fig.  22. — Egg  of    Trichocephakis   dispar. 

bothriocephalus  latus  of  greater  width  than  length,  but  are  char- 
acterized by  their  small  size,  so  that  about  one  hundred  and  fifty 
segments  may  be  counted  in  the  distance  of  one  centimeter.  The 
sexual  orifices  (again  as  in  the  bothriocephalus  latus)  are  not 
located  on  the  margin  of  the  joint,  but  in  its  center  and  all  on 
the  same  side.  The  eggs  are  oval  in  shape,  their  size  being  equal 
to  that  of  the  eggs  of  a  taenia,  from  which  they  easily  differ  by  the 


INTESTINAL    WORMS 


247 


Fig.  24 — T;enia  nana  (after  Leuckart). 
(b)  head,  (c)  hnok.  (d)  segment,  (e) 
egg. 


Fig.   23 — Taenia   nana    (Leuckar:). 


248 


INTESTINAL    WORMS 


shell ;  the  latter  is  thick  and  is  without  radiating-  stripes.  In  the 
egg"  the  embryo  may  be  seen,  armed  with  four  to  six  hooks.  (Figs 
23  and  24.) 

Taenia  cucumerina  is  only  seven  to  fourteen  inches  long, 
differing  decidedly  bv  this  feature  alone  from  other  fc^rms  of  taenia 


l"iy.  25 — r:enia  cucnmrnna  s.  cilipiioa   (, Lcuckart). 

whose  length  may  reach  several  feet.  The  other  important  dif- 
ference is  the  red  color  of  the  mature  segments  (which  are 
white  in  all  other  tceniae),  each  of  themlDeing  provided  with  two 
sexual  orifices,  one  on  each  side.     ]>v  the  structure  of  the  head  this 


Fig.  26 — Eggs  and  .segments  of  t.  solium,  nunliocan.  and  iKJtrioccphalus 
latus.  In  the  center  are  two  segments  of  natural  size,  and  in  the  upper 
row  they  are  enlarged. 

worm  is  most  similar  to  tccnia  solium,  because  it  has  four  stickers 
and  a  beak  surrounded  by  a  circle  of  hooks.  Infection  of  children 
occurs  through  dogs  by  means  of  a  peculiar  parasite  known  under 
the  name  of  trichodectes  canis.  This  intermediary  devours  the 
eggs  of  the  t;enia  which  occasionally  adhere  to  the  hairs  of  the 


INTICS'l'lNAI.    WdK.MS 


249 


(dogs,  becomes  contaminated  and  when  it  reaches  the  mouth  of  the 
child  affects  the  latter  with  the  t;enia.  (Fig-.  25.) 

BoTHKioCKi'iiALrs  1. ATI'S  casilv  dillers  from  the  two  other 
varieties  of  tsnia  by  the  structure  of  the  head  and  shape  of  the 
joints.     In  t?enia  solium  and  t.  mediocanellata  the  square-shaped 


Fig.   2"] — Tsenia   saginata   or  niecliocannelata :    (a)    natural   size   of   the 
worm  of   its   different  portions;    (b)    head;    (c)    segments. 

ihead  is  provided  with  four  round  suckers  and  in  the  former  with 
a  beak,  which  is  surrounded  by  hooks ;  in  bothriocephalus  latus 
the  head  is  oval  with  two  oblong-  dimples.  The  mature  segments 
of  the  first  two  kinds  are  square-shaped  in  form,  the  length  of 
•each  segment  is  nearly  one  and  a  half  times  that  of  the  l)readth, 


250 


INTESTINAL    WORMS 


but  in  the  bothriocephalus  latus  the  opposite  obtains,  the  trans- 
verse diameter  of  the  segment  is  greater  than  its  length.  The 
sexual  orifices  open  in  bothriocephalus  latus  in  the  center  of  the 
flat  surface  of  the  joint,  and  are  all  on  the  same  side,  while  in  the 
former  two  in  the  middle  of  the  margin.  (Fig.  26.) 

Taenia  solium  and  t.  medigcanellata  (P'ig.  27)  dififer 
from  each  other  only  as  regards  the  head,  their  joints  being  very 
similar,  the  only  difference  is  perhaps  in  t.  solium  the  matrix, 
which  is  in  the  middle  part  of  the  joint,  give  to  both  sides  fewer 
branches  (seven  to  tw-elve)  than  in  t.  niediocanellata  (twenty- 
five  to  thirty.)      (Figs  27  and  28.) 

In  order  to  see  these  branches  one  must  slightly  compress- 
the  segments  between  two  glass  slides  and  hold  to  the  light. 

For  t.  mediocanellata  it  is  somewhat  characteristic  that  its 
segments  not  infrequently  appear  in  the  stools,  while  in  t.  solium: 


Fig.   28 — Taenia    solium    (after   Lcuckart )  :    (a)    liead,    (b)    segments,    (c> 
cysticereus  a'lulosa   (turned  in — and  out). 

they  are  only  observed  in  rare  cases,  although  it  happens  some- 
times. Finally  the  history  may  be  of  service  in  the  diagnosis^ 
as  it  is  known  that  with  taenia  solium  man  becomes  infected, 
through  raw  pork,  but  t.  mediocanellata  through  beef. 

It  frequently  happens  that  the  presence  of  ascarides  or  of 
tai)eworms  in  the  bowels  is  not  manifested  by  any  symptoms,  be- 
ing recognized  only  after  elimination  of  the  whole  worm  (ascaris- 
lumbricoides),  or  of  single  segments  and  sections.  In  other  cases,, 
although  diverse  symptoms  on  the  part  of  the  nervous  system 
appear  (dizziness,  tendency  to  fainting,  grinding  of  the  teeth,, 
choreic  or  eclamptic  convulsions,  dilatation  of  pupils,  itching  of 
the  nose),  or  on  the  part  of  the  organs  of  digestion  (nausea  and 
vomiting  on  the  empty  stomach,  attacks  of  colic,  irregularity  of 
the  stools,  changeable  appetite),  or  on  the  part  of  the  general 


INTESTIXAL    \VOU^[S  25 1 

nutrition  (pallor,  nialii^naiit  aiucuiia — aiucinia  pcniiciosa,  general 
debilit}-,  irregular  fever),  yet  all  these  symptoms  are  to  such  de- 
gree non-characteristc  and  inconstant  that  they  can  only  give  rise 
to  suspicion  of  the  existence  of  worms. 

The  more  exact  diagnosis  is  based  either  on  microscopical 
examination  of  the  faeces  for  determining  the  presence  of  ova  of 
this  or  that  worm,  or  on  the  results  of  general  therapy. 

Regarding  the  eggs  these  always  may  be  found  in  cases  of 
oxyuris  vermicularis,  ascarides,  bothriocephalus  latus  and  taenia 
nana,  but  not  in  taeniae  solium  and  mediocanellata,  which  do  not 
deposit  their  own  ova  in  the  human  alimentary  tract,  their  dis- 
covery depending  upon  the  occasional  destruction  of  the  mature 
segment  in  the  intestines ;  but  these  two  specimens  of  worms  make 
themselves  evident  by  the  elimination  of  the  segments. 

If  ascarides  are  suspected  in  a  patient,  then  he  should  be  given 
a  few  powders  of  santonin  and  in  event  of  success  the  treatment 
is  continued  until  the  complete  expulsion  of  the  worms.  If,  how- 
ever, the  patient  suffers  from  taenia  solium,  then  after  a  few  days 
the  stool  may  show  segments  even  without  administering  specific 
remedies,  as  it  is  very  seldom  that  the  segments  fail  to  appear 
during  a  prolonged  period. 

The  diagnosis  of  t.  solium  is,  in  the  majority  of  cases,  effected 
by  the  circumstance  that  the  patient  himself  brings  to  the  physi- 
cian as  corpus  delicti  separate  segments  of  the  worm  or  whole 
chains. 


DISEASES  OF  THE  ORGANS  OF  RESPIRA- 
TION. 

DISEASES  OF  THE  UPPER  RESPIRATORY  PASSAGES. 

Snuffles — rhinitis,  s.  coryca.  This  morbid  condition  is 
shown  b}-  redness  and  swelHng  of  the  mucous  membrane,  and,  in 
acute  cases,  in  the  beginning-,  l)y  increased  secretion  of  transparent 
fluid  mucus ;  later  on,  and  in  chronic  cases,  by  a  more  dense 
muco-purulcnt  secretion.  If  the  latter  be  passive,  especially  in  the 
neighboring  cavities  of  the  cribriform  bones,  and  decomposes,  then 
an  odor  from  the  nose — chronic  fa^tid  coryza — is  present. 

The  diagnosis  of  coryza  does  not  exhibit  any  difficulties.  A 
question  may  arise  only  regarding  its  causes,  which  are  different, 
depending  on  whether  we  have  the  acute  or  chronic  form. 

Acute  rliinitis  seldom  develops  in  healthy  children  as  an  in- 
dependent malad}'  from  the  intluence  of  locally  acting  causes  or 
exposure  to  cold.  If  the  ])arents  complain  that  their  childrea 
take  cold  easily,  and  then  suft'er  from  rhinitis,  it  is  almost  certain 
that  we  have  to  do  with  exacerbations  of  a  chronic  rhinitis  or  with 
adenoids.  Especiall\  inclined  to  acute  rhinitis  are  those  children 
who  are  kept  within  doors  the  entire  winter,  or  who  are  too  much 
muffled  up.  In  some  cases  acute  rhinitis  is  the  result  of  saturation 
of  the  organism  w^ith  iodine.  The  nasal  secretion  is  characterized 
in  such  a  case  by  a  peculiar  foetor.  If  acute  rhinitis  develops  in 
a  new-born  child  on  the  second  or  third  day  of  his  life,  and 
from  the  very  first  a  great  quantity  of  purulent  secretion  appears, 
then  one  should  regard  such  a  coryza  as  due  to  the  gonococcus, 
that  is,  that  it  was  produced  by  infection  of  the  nasal  mucous 
membrane  from  the  vaginal  mucus  during  confinement.  This  is 
stlil  more  probable  if  the  child  suffers,  at  the  same  time,  with  a 
blenorrhagic  conjunctivitis.  The  final  establishment  of  the  diag- 
nosis depends  upon  the  result  of  bacterioscopic  examination.  It 
is  not  difficult  to  differentiate  a  gonococcus  coryza  from  a  syph- 


|)Isi-;asi-:s  uv  ui.snuAiom'  svstkm 


253 


ilitic  one,  because  the  latter,  besides  its  clironicity,  is  portrayed 
by  tlic  (h'xness  of  the  mucous  nK'nil)raue  of  the  nose. 

Acute  coryza  frequently  expresses  the  general  ill-health  of 
the  organism,  namely  la  grippe  or  measles  (seldom  whooping- 
cough),  being  in  such  instances  accompanied  by  catarrh  of  other 
organs,  eyes,  bronchi,  etc.  Snuffles  appears  among  the  first  symp- 
toms of  these  diseases,  thus  permitting  one,  in  the  case  of  any 
epidemic,  to  make  a  diagnosis  even  before  the  appearance  of  more 
definite  symptoms  (see  the  section  on  T.a  grippe).  The  important 
significance  of  coryza,  in  the  diagnosis  of  a  beginning  febrile  dis- 
ease, is  further  apparent  inasmuch  as  this  symptom  serves  as  a  cri- 
terion in  excluding  certain  diseases  which  may  be  confoimdcd 
with  la  grippe  during  the  first  days  of  the  affection,  but  for  which 
coryza  is  not  symptomatic  at  all,  as,  for  instance,  typhoid  fever, 
relapsing  fever,  smallpox,  scarlet  fever. 

In  other  cases  the  mucous  membrane  of  the  nose  is  the  place 
of  primary  localization  of  diphtheria. 

Primary  diphtheria  of  the  nose  occurs  in  two  forms:  ma- 
lignant and  benign.  The  main  symptom  of  the  disease,  in  both 
forms,  which  distinguishes  it  from  any  other  kind  of  rhinitis, 
consists  in  the  jM^esence  on  the  mucosa  of  the  nose  of  fibrinous 
membranes  which  are  readily  observed  as  soon  as  they  involve 
the  nostrils ;  however,  if  they  occupy  the  posterior  parts,  then  they 
may  be  made  out  by  syringing  the  nose  or  cleansing  the  same  with 
a  tampon.  The  essential  difference  between  these  forms  consists 
in  the  fact  that  during  malignant  diphtheria  of  the  nose,  one  can 
say  at  once  that  the  patient  is  severelv  sick ;  the  face  expresses 
weakness,  the  temperature  is  high  (39  degrees  C. — 102.2  degrees 
F.  and  more),  the  submaxillary  glands  are  swollen.  A  few  days 
later  diphtheria  usually  extends  over  the  fauces.  This  is  a  disease 
of  small  children,  especially  under  one  year  of  age. 

In  the  benign  form  of  diplitheria  of  the  nose  fever  is  either 
entirely  absent  or  is  present  only  during  the  first  days,  the  disease 
continuing  either  with  a  normal  or  slightly  elevated  temperatur-e 
(about  37.5  degrees  C. — 99.5  degrees  F.),  the  general  condition 
suffering  so  little  that  the  patient  gives  the  impression  as  if  suf- 
fering with  a  common  catarrhal  rhinitis.  In  brief,  the  benign 
form  of  diphtheria  of  the  nose  is  a  purely  local  disease,  and  in 
distinction  from  the  maliijnant  form  is  described  under  the  name 


254  DISEASES   OF    RESPIRATORY    SYSTEM 

of  fibrinous  rhinitis — rhinitis  Hbrinosa,  s.  memhranacca.  It  is  a 
remarkable  fact  that,  despite  the  local  and  general  symptoms 
being  mild,  fibrinous  rhinitis  is  a  very  obstinate  disease,  the  mem- 
branes persisting  about  three  weeks  or  more. 

That  these  benign  forms  belong  only  to  diphtheria  one  can 
see,  first,  from  the  bacterioscopic  examination,  detecting  Loffler's 
bacillus  in  the  great  majority  of  cases  in  the  nasal  secretion,  which 
is  plainly  pathogenic  for  animals ;  and,  second,  that,  notwith- 
standing the  slightness  of  the  contagiousness  of  such  rhinites,  in- 
fection occurs  to  surrounding  individuals  in  whom  diphtheria  of 
the  fauces  develops. 

Rhinitis  fibrinosa,  like  any  membranous  affection  of  the 
fauces,  is  not  always  of  diphtheritic  origin,  that  is,  is  not  always 
produced  by  Loftler's  bacillus.  Upon  bacterioscopic  examination 
only  the  staphylococcus  or  some  other  microbe  may  be  detected. 
Such  pseudo-diphtheria  of  th.e  nose  is  held  as  non-infectious. 

Staphylococcus  fibrinous  rhinitis  occurs  especially  often  after 
actual  cauterization  of  the  nasal  mucosa ;  upon  the  place  of  cauter- 
ization the  membranes  disappear  and  reappear,  but  only  the 
staphylococcus  may  be  detected. 

CiiROXic  RHINITIS  differs  from  the  acute  by  the  fever  being 
absent  and,  especially,  by  its  duration.  In  older  children  it  is 
usually  accompanied  by  adenoid  granulations  in  the  naso-pharyn- 
geal  cavity  and  serves  as  a  frequent  symptom  of  scrofula ;  while 
in  children  one  to  three  years  of  age  it  usually  accompanies  ec- 
zema on  the  face;  but  in  new-born  children  the  rhinitis  is  a  very 
important  sign  of  inherited  syphilis.  This  symptom  is  held  as  an 
important  one,  first,  because  of  its  early  appearance  (earlier  than 
many  other  symptoms  of  syphilis),  and,  second,  because  it  is 
rarely  absent  in  inherited  syphilis. 

From  an  acute  cor)za,  which  also  may  occur  in  the  new- 
born, coryza  syphilitica  differs  by  its  slow  course,  dry  catarrh 
and  absence  of  catarrh  of  the  neighboring  mucous  membranes 
(eyes,  bronchi).  During  an  ordinary  rhinitis  a  discharge  appears, 
the  catarrh  being  prone  to  spread  over  the  neighboring  organs, 
because  in  the  majority  of  cases  the  same  is  a  form  of  la  grippe. 

It  is  further  suspicious  if  epistaxis  or  a  sanious  secretion 
shows  once  in  a  while  during  coryza  in  a  child  several  days  of 
age.     Both  these  symptoms  also  happen  during  diphtheria  of  the 


i)isi-:.\si':s  c)i'  Ki-:si'iK.\  lom-  snsiicm  255 

nose,  but  then  the  corvza  is  accompanied  by  more  or  less  fever 
(which  is  absent  in  coryza  syphihtica).  This  (|nestion  may  also 
arise  if  rhinitis  appears  in  an  abortive  child  despite  correct  hy- 
gienic measures.  All  doubt  disappears  when  other  s}mptoms 
of  syphilis  develop  after  a  short  time  (see  section  on  Syphilis). 

If  chronic  rhinitis  is  caused  by  adenoid  veg^etations  in  the 
naso-pharyngeal  cavity,  then  it  is  not  difficult  to  recognize  their 
presence.  The  external  aspect  of  such  patients  is  quite  charac- 
teristic, at  least  in  typical  cases.  We  then  have  to  deal  usually 
with  children  live  to  twelve  years  of  age,  although  adenoids 
may  be  met  with  in  very  small  children,  being  frequently  in- 
herited. The  mother  consults  the  physician  because  her  child 
snores  while  sleeping  and  often  awakens,  because  the  child  easily 
catches  cold  and  repeatedly  takes  ill  with  cough  and  snutfles. 
At  a  glance  there  are  to  be  noticed  a  tired  look,  loiig  face  (flat- 
tened cheeks),  narrowed,  immobile  nostrils,  thin  nose  and  a  half- 
opened  mouth.  In  the  presence  of  such  symptoms  one  may  sup- 
pose with  great  probability  the  existence  of  adenoid  vegetations 
in  the  naso-pharyngeal  cavity,  but  in  order  to  convince  himself 
the  physician  must  examine  the  fauces  with  the  finger.  Normally, 
the  mucous  membrane  is  smooth  and  as  it  is  attached  immedi- 
ately to  the  base  of  the  skull  and  to  the  vertebral  column  ;  the 
examining  finger  directly  feels  the  underlying  bone.  In  case, 
however,  of  adenoids  there  occurs  a  larger  or  smaller  lobular 
tumor,  of  quite  soft  consistency. 

As  adenoid  vegetations  produce  impermeability  of  the  nose, 
they  lead  to  different  other  consequences ;  as,  for  instance,  it  is 
obvious  that  the  sense  of  smell  must  suffer,  and  simultaneously, 
of  course,  the  sense  of  taste.  The  obstructed  breathing,  espe- 
cially at  night,  often  causes,  in  small  children,  narrowing  of  the 
chest  with  prominence  of  the  sternum,  as  in  the  rachitic  chest. 
Disturbance  O'f  respiration  also  causes  disorders  of  blood-forma- 
tion, that  is,  the  general  nutrition  suffers ;  the  child  is  pale,  weak, 
takes  little  food,  complains  of  frequent  headache,  is  inattentive  in 
school  and  his  ability  to  think  is  poor.  Because  of  obstruction  of 
the  Eustachian  tube  (by  the  proliferating  adenoids  or  the  accumu- 
lation of  catarrhal  mucus)  children,  suffering  from  adenoid  vege- 
tations, complain  very  often  of  poor  Hearing.  The  latter  increases 
still  more  if  the  catarrh  spreads  from  the  pharynx  to  the  middle 


256  DISEASES   OF   RESIM  RATORV    SYSTEM 

ear,  prcxlucing-  perforation  of  the  membrana  tympani  and  chronic 
otorrhoea.  Such  otites  in  small  children  may  result  in  deaf-mut- 
ism, unless  the  cause  of  the  disease  (adenoids)  be  removed  at  the 
proper  time. 

[Adenoid  vegetations  may  also  be  the  cause  of  convulsions 
and  spasm  of  the  glottis.  Maaloe  had  the  opportunity  to  treat 
ten  children  who  suffered  with  spasm  of  the  glottis  or  convul- 
sions ;  five  of  them  had  only  convulsions,  in  the  other  five  the 
convulsions  were  combined  with  glottis  spasm.  As  no  cause  of 
the  convulsions  could  be  found,  Maaloe  looked  for  adenoid  vege- 
tations, which  were  present  in  all  ten  children.  The  removal  of 
the  adenoids  led  to  the  complete  recovery  of  all.  One  of  them  had 
a  relapse,  but  a  repeated  careful  curettage  caused  full  recovery. 
One  of  the  operated  children  was  only  eight  months  old,  the 
others  under  one  year  of  age.  The  action  of  the  adenoids  was 
apparently  a  reflex  one.* 

Furthermore,  cases  are  reported  in  literature  which  show 
that  adenoids  are  also  the  cause  of  incoiitiiiciicc  of  the  urine.  One 
such  case  was  reported  by  Kantorovitch.  A  twelve-year  old  boy 
zvho  had  suffered  since  si.v  years  of  age  from  involuntary  mic- 
turition. The  family  history  of  the  patient  was  good ;  aside  from 
measles,  no  other  disease  could  be  found  in  his  personal  history. 
All  kinds  of  treatment,  dietetic  measures,  etc.,  remained  without 
any  result.  Upon  examination  of  the  posterior  nasal  cavity,  Kan- 
torovitch found  adenoid  vegetations  quite  well  developed.  In 
four  currcttements  he  completed  the  removal  of  all  adenoids.  The 
first  operations  resulted  in  a  lessening  of  the  frequency  of  the  in- 
voluntary micturitions  and  for  three  months  after  the  last  opera- 
tion there  was  no  incontinence.** — Earle.] 

If  chronic  rhinitis  be  persistent  in  one  side  of  the  nose,  then 
we  may  suspect  either  a  foreign  l)od)-  in  the  nose  (examination 
with  the  sound),  or  a  polypus. 

[Chronic  foetid  rhinitis.  atrof'Jiic  rJiinitis,  "ozccna"  or  "true 
ozccim"  is  described  by  different  authors  as  a  chronic  affection 
of  the  nose  distinguished  by  : 

(i)  Atrophy  of  the  Schneiderian  mucous  membrane  of  the 
nose. 


^Abstract  in  La  Scmainc  Mcdicalc.  1903,  p.  84. 
^*Abstract  in  La  Sciiiaiiic  Mcdicalc,  1903,  p.  83. 


DISEASES   OF   RESl'lUATOUV    SYSTEM  25/ 

(2)  Atrophy  of  the  turbinates. 

(3)  By  wide  nasal  fossae. 

(4)  A  Feet  id  odor,  and 

(5)  Tlie  formation  of  scabs. 

It  (icciu-s  (|uitc  often  in  childhood  (Riviere  met  this  affection 
in  early  childhood  in  lo  per  cent  in  all  cases  of  ozsenous  patients 
he  treated)  and  in  females  oftener  than  in  males   (Symes). 

The  variet}-  of  names  given  to  this  chronic  foetid  aft'ection  of 
the  nose  is  explained  by  Moure*  (Bordeaux,  France)  by  the 
variety  of  clinical  forms  it  possesses,  as  well  as  by  the  period  at 
which  the  examination  is  made,  and  the  ag'e  of  the  patient. 

.Etiologically  this  disease  is  not  well  established.  The  com- 
monest views  regarding-  this  subject  are  as  follows : 

(i)  Symes  believes  that  atrophic  rhinitis  may  be  regarded 
as  a  chronic  form  of  nasal  diphtheria:  he  fo'und  in  tw^enty  cases 
out  of  fift}-seven  of  ozasna  a  bacillus  resembling  in  its  morpholog- 
ical and  cultural  characteristics  the  Klebs-Loffler  variety ;  and  the 
correctness  of  such  a  view  is  borne  out,  in  his  opinion,  bv  the 
further  fact  that  ozaena  sometimes  yields  to  the  treatment  with 
diphtheritic  antitoxine. 

(2)  According  to  Griinwald  ozrena  is  not  a  primary  disease, 
but  a  secondary  process  due  to  inflammation  of  the  nasal  sinuses, 
viz,  sinusitis.  This  theory  has  been  abandoned  by  the  majority 
of  specialists  as  careful  examination  of  the  nasal  sinuses  does  not 
show  in  most  cases  any  connection  between  affections  of  the 
sinuses  and  ozaena. 

(3)  Sticker  thinks  ozaena  depends  on  some  parasyphilitic 
affection  called  by  him  xerosc,  which  would  be  nothing  but  an 
atrophy  of  the  whole  organism  producing  enlargement  of  the 
nasal  cavities,  of  the  pharynx,  bronchi  and  lungs. 

(4)  Lately  a  new  theory  has  been  advanced  by  Freudenthal 
(Xew  York)  in  a  paper  presented  at  the  last  (Madrid)  meeting 
of  the  International  Medical  Congress.  This  is  the  so-called 
"dry-air  theory."  According  to  this  author,  ozasna  is  atrophy  of 
the  nasal  interior  due  to  atmospheric  influences,  especiallv  to  the 
too  great  dryness  of  the  air — xerasia.    The  existing  atrophic  con- 

*Moure:  Paper  read  at  the  meeting  of  the  ^^ladrid  Inleniational  Medi- 
cal Congress,  190.3  (quoted  from  Frogressii'c  Mciiic.  1904.  \'ol.  VI.,  N.  i, 
p.  274). 


258  DISEASES   OF    RRSIMRATORV    SYSTEM 

dition,  in  connection  with  the  atmospheric  influences,  favors  the 
growth  and  niultiphcat'on  of  microbes  similar  to  Friedlander's 
pneumobacillus.  whicli.  on  the  suitable  soil,  produce  ozsena.* — 
Earle.  ] 

Epistaxis  (nose-bleed)  is  by  itself  easily  recognized,  but  the 
cause  is  not  always  readily  detected.  If  the  bleeding  occurs 
from  the  ])osterior  parts  of  the  nose,  while  the  patient  is  keeping 
a  dorsal  posture,  then  the  blood  may  flow  backwards  down  the 
posterior  wall  of  the  pharynx  into  the  stomach  and  then  be  ex- 
pelled by  vomiting — a  false  l)loody  vomiting.  The  source  of 
epistaxis  becomes  evident  either  by  the  presence  of  blood-clots 
in  the  nose,  or  by  remains  of  blood  on  the  posterior  pharyngeal 
wall,  or,  at  least,  by  the  further  observation  of  the  patient,  while 
he  is  in  bed  with  the  head  only  slightly  elevated. 

/Etiologically  nose-bleeding  may  be  separated  into  two  di- 
visions :  to  the  first  belongs  occasional  epistaxes  resulting  from  the 
influence  of  certain  transitory  causes  and  therefore  not  repeated. 
There  may  be  included  here,  for  instance,  traumatic  nose-bleed, 
as  well  as  epistaxis  during  acute  infectious  diseases,  especially  in 
typhoid,  measles,  relapsing  fever  and  morbus  maculosus  Werlhofii. 

To  the  second  division  may  be  referred  cases  of  repeated 
epistaxes,  frequently  occurring  without  any  cause.  Thus  first  of 
all  the  so-called  habitual  epistaxes,  for  which  very  often  no  espe- 
cial causes  are  to  be  detected,  so  that  one  must  admit  the  "indi- 
vidual predisposition"  to  rupture  of  the  capillaries  of  the  nasal 
mucous  membrane  under  the  influence,  for  instance,  of  heredity 
or  hemophilia.  It  is  noteworthy  that  the  age  is  here  imixDrtant; 
in  children  under  four  or  five  years  these  habitual  haemorrhages 
are  very  infrequent,  but  from  seven  up  to  twelve  vears  they  occur 
often.  According  to  Rendu'''*  habitual  nose-bleed  not  infrequently 
occurs  in  children  seeniingly  entirely  well,  but  the  history  shows 
that  they  have  suffered  for  a  long  time  with  indistinctly  devel- 
oped rheumatoid  pains,  their  urine  is  turbid,  with  a  sediment  of 
uric  acid  salts.  Such  children  often  sufifer  with  migraine.  The 
nasal  congestion  ending  wMth  h?emorrhage  is  in  such  cases  entirely 
analogous  to  acute  rheumatic  congestion  of  the  joints  m  older 
patients,   and   an   antiarthritic   diet   should  be  then   administered 


*Quoted  from  Progrcssn'c  Medicine,  Vol.  VI.,  No.  i,  1904.  p.  273. 
**Rez'ue  mois.  des  maladies  de  I'eiif.    1884. 


DISEASES   OF    KKSIMkATdRN'    SNSIKM 


259 


to  the  cliikl  (alkaline  water,  less  meat,  and  wine  shcnild  be  entirely 
forbidden ) . 

Predisposition  to  b?emorrhage  being  present,  the  exciting 
causes  may  be  as  follows :  liigh  temperature  of  the  room  or  of  the 
air  (many  children  suffer  with  nose-bleed  only  during  the  hot 
summer  days)  ;  forced  mental  work  in  a  sitting  posture,  the 
body  being  bent,  and  especially  when  the  collar  is  tight ;  tire- 
some physical  exercises,  for  instance,  during  play ;  and  finally, 
according  to  some  authors,  masturbation  and  the  period  of  ])ubertv 
in  girls. 

In  other  cases  habitual  nose-bleed  is  a  symptom  of  chronic 
cardiac  lesion  or  of  diseases  of  the  blood,  as  true  or  false  leukc'c- 
mia  and  chlorosis.  Epistaxes  occurring  daily,  sometimes  several 
times  during  the  day,  after  paroxysms  of  violent  cough,  points 
with  great  probability  to  whooping-cough. 

Of  nose  diseases,  polypi  and  ulcerous  conditions  may  cause 
repeated  epistaxis.  The  common  location  of  the  hsemorrhage  is  the 
cartilage  of  the  nasal  septum,  w'here  very  often  small  ulcers 
occur,  leading  to  repeated  bleeding  during  many  months  in  suc- 
cession ;  and  to  various  dilated,  or  small  vessels,  wdiich  break  and 
thus  cause  a  persistent  nose-bleed.  It  is  very  important  for  thera- 
peutic purposes  to  be  accjuainted  with  these  two  causes  of  "re- 
peated" hsemorrhage,  because  a  hsemorrhage  which  had  not  yield- 
ed to  any  treatment  for  months  wnll  frequently  entirely  disappear 
after  a  single  cauterization  of  the  nasal  septum  with  the  Pac- 
ciuelin. 

It  is  noteworth)-  that  acute  rhinitis,  although  always  ac- 
companied by  considerable  hypera^mia  of  the  mucous  membrane, 
almost  never  leads  to  nose-bleed ;  more  often  bleedings  are  ob- 
served during  chronic  rhinitis  because  of  adenoid  vegetations. 
Rhinitis  with  a  sanious  discharge  in  new-born  children  commonly 
occurs  during  hereditary  syphilis. 

In  two  cases  of  mine,  in  a  girl  six  years  of  age  and  another 
one  eleven  years,  nose-bleed  was  repeated  for  several  days  in 
succession,  and  each  time  at  between  twelve  and  two  o'clock  p.  m. 
during  sleep.  Both  stopped  after  one  dose  of  quinine,  therefore 
1  regard  them  cases  of  febris  intermittens  larvata. 


200  DISEASES   OF    RESPIRATORY    SYSTEM 

DISEASES  OF  THE  LARYNX  AND  TRACHEA  CHARAC- 
TERIZED BY  STENOTIC  RESPIRATION. 

L'nder  the  name  of  stenotic  breathing  we  understand  a  symp- 
tom-complex depending  upon  narrowing  of  the  hu-}nx  and 
trachea.    It  is  easy  to  recognize  stenotic  breathing. 

I'irst,  it  is  always  accompanied  by  a  peculiar  noise,  which  the 
air  produces  while  passing  through  the  constricted  part,  known 
as  inspiratory  stenotic  noise. 

Second,  because  of  hindered  access  of  air  to  the  lungs,  the 
latter  cannot  coincidently  follow  the  expansion  of  the  chest  dur- 
ing inspiration,  therefore  a  vacuum  in  the  chest  is  produced.  This 
causes  the  ap]:)carances  of  forced  inspiration,  that  is,  depression 
of  the  \ielding  portions  of  the  chest  in  the  form  of  deepening  of 
the  supra-clavicular  and  jugular  fossa;  during  the  act  of  inspira- 
tion, as  well  as  of  the  intercostal  spaces  and  especially  of  the  epi- 
gastrium and,  in  general,  of  the  lower  periphery  of  the  chest 
along  the  points  of  attachment  of  the  diaphragm  (as  the  latter 
also  becomes  concerned,  it  cannot  therefore  sink  during  inspira- 
tion, and  so  it  depresses  by  its  contractions  the  lower  periphery 
of   the  chest). 

Third,  the  obstructed  air  supply  of  the  lungs  causes  dyspnoea, 
because  of  which  the  patient  reinforces  all  his  accessory  inspira- 
tory muscles.  This  manifests  itself  by  dilatation  of  the  nostrils- 
and  marked  contraction  of  the  neck  muscles. 

Thus,  the  chief  symptoms  of  stenotic  breathing  arc  stenotic 
inspiratory  noise,  drawing  in  of  the  yielding  portions  of  the  chest 
and  the  actioii  of  the  accessory  muscles. 

If  the  dyspnoea  does  not  depend  upon  stenosis  of  the  trachea 
or  larynx,  but  upon  diseases  of  the  lungs  or  small  bronchi,  then 
there  may  also  occur  depression  of  the  yielding  portions  of  the 
chest  together  with  the  forced  contraction  of  the  accessory  mus- 
cles, but  there  is  absent  the  characteristic  stenotic  sound. 

In  treating  stenotic  respiration  we  must  decide  the  questions 
regarding  its  degree,  the  place  of  narrowing,  and  its  cause. 

It  is  important  to  know  the  degree  of  stenosis,  because  upon 
this  depends  not  only  the  diagnosis,  but  also  the  therapeutic 
measures,  and  likewise  the  proper  decision  of  the  question  re- 
garding tracheotomy.  Any  division  of  stenosis  into  degrees  will 
be,  of  course,  arbitrarv,  because  between  the  slightest  and  the 


DISEASES   OF    RESlMKAlom'    SVSTEAl  261 

severest  cases  there  exist  all  possible  gradations ;  yet  approxi- 
mately three  degrees  of  stenosis  may  be  distinguished:  (i)  the 
slight,  (2)  moderate,  and  (3)  the  grave. 

In  slight  cases  stenotic  noise  and  other  symptoms  appear 
only  during  inspiratory  movements,  for  instance,  during  the  cry, 
while  in  quiet  respiration  no  signs  of  hindered  access  of  the  air  to 
the  lungs  are  to  be  noticed. 

Cases  of  motlerate  severity,  which  are  not  immediately  dan- 
gerous and  which  do  not  call  for  an  urgent  tracheotomy,  are 
characterized  by  the  fact  that,  although  the  stenotic  noise,  the 
drawing  in  of  the  yielding  portions  of  the  chest  and  the  action 
■of  the  neck  muscles  are  seen  during  quiet  respiration,  the  patient 
can  compensate  the  consequences  of  the  stenosis,  so  that  he  does 
not  undergo  an  oxygen  starvation  and  does  not  exhibit  symptoms 
of  retarded  blood  circulation  in  the  form,  for  instance,  of  cyanosis. 

Finally,  grave  cases  are  indicated  by  the  patient  indicating 
lack  of  oxygen ;  he  suffocates,  being,  therefore,  very  restless ;  his 
face  expresses  painful  anxiety ;  he  throws  himself  about  in  the 
"bed,  grasps  at  his  neck,  etc.  Because  of  the  aspiration  of  blood 
to  the  lungs  the  arteries  become  empty  (pale  face  and  cold  limbs), 
but  the  veins  become  overfilled  (cyanosis  of  the  lips  and  fingers). 
Such  a  condition  cannot  last  long,  and  if  the  obstacle  be  not  im- 
mediately removed,  then  the  patient  will  either  die  during  the 
attack  of  suffocation,  for  instance,  because  of  occasional  obstruc- 
tion of  the  constricted  point  with  a  lump  of  mucus,  or  he  falls 
into  a  condition  of  somnolence  and  collapse,  the  breathing  becom- 
ing shallow  and  not  so  noisy,  the  pupils  dilated,  the  cyanosis 
increases ;  finally  general  ansesthesia  sets  in  and  the  patient  suc- 
cumbs to  carbon  dioxide  poisoning. 

The  determination  of  the  place  of  stoiosis  brings  into  ques- 
tion the  throat,  the  larynx  and  the  trachea. 

If  a  laryngoscopic  examination  of  the  patient  is  possible,  then 
the  difficulty  becomes  cleared  away  very  easily,  and  the  physician 
defines  at  once  not  only  the  place  of  stenosis,  but  also  its  cause. 
Unfortunately  laryngoscopy  is,  in  children,  not  often  applicable 
and  one  must  make  the  diagnosis  without  it. 

Obstacles  on  the  part  of  the  fauces,  either  in  the  form  of 
considerably  swollen  tonsils  or  of  a  retro-pharyngeal  abscess, 
may  be  comparatively  easily  determined  b\-  the  eye  and  the  finger, 


262  DISEASES   OF    RESI'IRATORV    SYSTEM 

but  it  is  not  always  easy  to  distinguish  stenosis  laryngis  from  that 
of  the  trachea.  Besides  the  course  of  the  disease,  we  are  also 
giiided  by  the  peculiarity  of  voice  and  cough,  as  well  as  by  the 
excursions  of  the  larynx.  If  the  patient's  voice  appears  harsh,  and 
the  cough  ringing  (short  spell  with  a  coarse  coughing  sound,  "the 
patient  coughs  as  if  in  a  barrel,"  as  the  mother  relates),  then 
the  point  of  stenosis  is  in  the  lar\nx.  This  rule,  however,  admits 
of  exceptions ;  on  one  part,  the  voice  ma}'  reniain  clear  during 
afifection  of  the  larynx,  for  instance,  in  bilateral  paralysis  of  the 
muscles  which  dilate  the  glottis;  on  the  other  hand,  it  may  also 
be  changed  during  tracheal  stenosis,  for  instance,  owing  to  com- 
plications with  laryngeal  catarrh  or  simply  because  of  the  small 
volume  of  air  dmnng  the  obstructed  expiration.  If  the  stricture 
reaches  a  certain  degree,  then,  in  the  case  of  laryngeal  affection, 
there  is  noticed  a  lowering  of  the  larynx  toward  the  jugular 
fossa  (in  conseciuence  of  aspiration),  which  appearance  is  absent 
it  the  stenosis  occupies  the  lower  part  of  the  trachea. 

In  the  diagnosis  of  the  ])laceof  stenosis  one  may  also  i>e 
guided  by  the  fact  that  almost  all  cases  of  acute  development  of 
stenosis  of  the  resj)iratory  passages,  except  when  due  to  foreign 
bodies,  are  to  be  referred  either  to  the  larynx  or  to  the  fauces, 
but  not  to  the  trachea ;  whereas  in  chronic  cases,  either  to  the 
trachea,  to  the  larynx  or  to  the  fauces. 

^■Efiolooically  all  stenoses  of  the  u])]ier  res])iratory  passages 
may  be  divided  into  acute  and  chronic.  To  the  former  belong 
phlegmonous  angina,  retro-])har\ngeal  abscess,  false  and  true 
croup,  foreign  bodies  in  the  larynx,  spasm  glottidis  and  its  cedema. 
To  the  chronic  variety  belong  new  growths  in  the  larynx,  espe- 
cially papillomata  and  syphilis,  perichondritis,  compression  of  the 
trachea  by  tumors  of  the  thyroid  and  thymus  glands  or  by  over- 
growth of  the  lymphatic  glands  of  the  neck  and  bronchi. 

ACUTE  DISEASES  OF  THE  LARYXX  PRODIXTXG  ITS 

STENOSIS. 

Acutely  arising  stenosis  of  the  larynx  most  often  occurs  in 
children  during  catarrhal  or  fibrinous  inflanmiation  of  the  laryn- 
geal membrane,  that  is,  during  false  and  true  croup. 

Under  the  name  of  false  rroitp  we  understand  a  catarrh  of 
the  larynx,  in  which  the  swelling  of  the  mucous  membrane  causes 
narrowing  of  the  lumen  of  the   larynx  and  consequent   stenotic 


nisi:ASF.s  nr  RF.siMR.\roR\-  svstf.m  26^ 

respiration.  As  Ixauclifuss  has  shown,  attacks  of  falsi-  cninj) 
especially  arise  in  those  cases  wherein  swelling-  of  the  snhnnic- 
ons  tissue  appears  immediately  under  the  vocal  cords,  hence  the 
naiue  larxiio;itis  siibclwrdalis. 

In  TRUE  CROfp  we  have  to  do  with  crotif^oiis  iii/laiiiiiiotion  of 
the  nuicous  memhrane  of  the  larynx,  which  is  marked  by  the 
formation  of  a  fibrinous  membrane  over  the  whole  surface  of  the 
latter.  A  true  croup  has,  in  the  ^reat  majority  of  cases,  a  diph- 
theritic orig"in.  therefore,  in  the  fibrinous  membranes,  as  well  as  in 
the  mucus  taken  from  the  posterior  wall  of  the  larynx,  the  Loflf- 
ler  bacillus  may  be  found;  l)ut  sometimes  cases  of  membranous, 
that  is,  true,  criutji  are  seen  due  to  stai:ih.ylococcus.  streptococcus 
or  of  other  orit^in,  as  occurs  also  in  membranous  inflammation 
of  the  fauces. 

Although  in  both  these  cases  we  have  almost  the  same  s}'mp- 
toius.  namely,  stenotic  respiration,  hoarse,  rintjiuij;'  cousi^h  and 
harsh  voice,  nevertheless.  In  the  overwh.elmin.i;-  majority  the  differ- 
ential diag'uosis  is  not  at  all  difficult.  The  marked  difference  be- 
tween false  and  true  croup  is  exident  from  the  ver\  be^iiuiing 
of  the  disease. 

False  croup  begins  siiildciily :  the  patient  goes  to  bed  in  an 
entirely  healthy  condition;  (he  had.  perhaps,  a  mild  cold  and  ,1 
slight  cough)  ;  he  sleeps  well  for  about  two  or  three  hom\s  and 
then  suddenly  awakens  with  a  rough  cough  and  obstructed  res- 
piration, while  die  stenosis  may  reach  even  the  grave  degree. 
Such  symptoms  usually  do  not  last  long ;  in  favorable  cases  im- 
proving after  fifteen  to  thirty  minutes,  in  severe  cases  after  one 
or  two  hours,  the  appearances  of  stenosis  abate  and  the  patient 
falls  asleep  until  morning.  In  the  morning  he  brealhes  freely, 
the  stenosis  has  disappeared  entirely  or  is  noted  only  during  the 
cry  (to  a  slight  degree),  the  cough  beciMiies  more  moist,  but  is 
still  of  a  rough  character.  The  next  night  the  attack  of  stenotic 
breathing  ma\-  reappear,  being  usually  weaker  than  on  the  first 
occasion,  and  in  general  the  patient  each  subsequent  day  feels 
better,  and  soon  he  recovers  entirel\'. 

True  croup  never  begins  suddenly.  P>efore  this  form  reaches 
a  grave  degree  of  stenosis  the  ])atient  for  two  or  three  <la\"s  ex- 
hibits symptoms  of  a  catarrh  of  the  larynx.  The  voice  in  the  be- 
ginning is  not  regarded  as  harsh ;  the  cough  is  infrequent  and 


264  DISEASES   OF   RESPIRATORY    SYSTEM 

easy ;  no  stenosis  is  present.  The  next  day  all  symptoms  increase, 
the  coup^h  assumes  at  times  a  ringing  character,  hoarseness  de- 
velops and  a  mild  degree  of  stenosis  sets  in  (during  the  cry). 
On  the  third  day  the  patient  feels  still  worse,  and  if  the  disease 
produces  a  considerable  degree  of  stenosis,  then  this  lasts  during 
all  the  twenty-four  hours,  increasing  at  times  to  the  point  of  fatal 
suffocation,  then  decreasing,  but  never  with  free  intervals,  as 
during  false  croup.  If  the  patient  be  not  suffocated  during  one 
of  his  attacks  then  be  passes  (in  very  acute  cases  after  one  to  three 
days,  in  milder  after  five  or  ten  days)  into  a  condition  of  collapse, 
dving  with  symptoms  of  slow  carbon  dioxide  poisoning. 

Briefly  speaking,  we  have,  as  characteristic  of  false  croup,  the 
sudden  and  rapid  development  of  symptoms  of  stenosis  of  the 
larynx  and  their  short  duration,  while  in  the  true  variety  there 
is  the  gradual  onset  and  the  progressive  increase  of  symptoms 
of  stenosis  continuing  for  sezeral  days. 

The  degree  of  stenosis  by  itself  is  of  no  diagnostic  value,  be- 
cause a  very  considerable  narrowing  of  the  larynx  may  also 
appear  during  false  croup ;  the  duration  of  the  attack  is  of  more 
importance.  In  false  croup  the  stenosis  develops  (juickly  but  does 
not  last  long,  not  more  than  a  couple  of  hours ;  in  true  croup 
the  development  of  stenosis  occurs  gradually  and  progressively 
and,  when  developed,  it  remains  until  death,  or  at  least  for  a  few 
davs  until  the  period  of  recovery  sets  in.  The  convalescence  is 
also  gradual  in  true  croup,  and  therefore  if  the  attacks  of  stenosis 
not  only  do  not  disappear  after  twenty-four  hours,  but  even  in- 
crease, then  it  is  most  probably  that  we  have  a  true  croup  to  care 
for.  We  say  "most  probable,"  but  not  "positively,"  because,  as 
rare  exceptions,  there  happen  such  severe  cases  of  false  croup 
that  the  patient  either  dies  from  suffocation,  or  suffers  from  in- 
terrupted stenosis  of  the  larynx  for  two  or  three  days. 

In  false  croup  there  is  observed  an  absence  of  correspoiidencr 
between  the  degree  of  stenosis  and  the  hoarseness  of  the  voice 
and  cough ;  that  is,  there  may  be,  for  instance,  a  ringing  cough 
and  labored  respiration,  while  the  voice  is  quite  clear  (when  the 
normal  vocal  cords  are  associated  with  a  large  tumor  of  the 
subchordal  mucous  membrane — Rauchfuss,  Dehio),  especially 
during  crying  the  voice  often  appears  quite  loud ;  or,  vice  versa, 
the  voice  disappears,  aphonia  arises,  while  the  cough  is  at  the 


DISEASES    OF    RliSl'IRAIORV    SVS'J  l-:.\l  26"^ 

same  time  not  very  harsh  and  stenosis  is  ahnost  absent  (when  tlic 
catarrhal  swelHng-  of  the  true  vocal  cords  is  not  associated  with 
the  marked  swelling-  of  the  subchordal  mucous  membrane). 

In  true  croup,  on  the  contrar\-,  all  these  evidences  are  de- 
veloped proportionately  to  each  other,  so  that  if  a  pronounced 
■stenosis  of  the  larynx  takes  place,  then  the  voice  will  be  aphonic 
and  the  cough  ringing. 

The  cough,  being  in  the  beginning  of  a  majority  of  cases  of 
true  croup,  slight  and  not  harsh,  becomes  later  on  more  frequent 
•in  occurrence,  stronger  (paroxysmal)  and  rougher.  On  the  con- 
trary, in  laryngeal  catarrh,  the  cough  at  once  assumes  a  harsh, 
ringing  character,  being  very  frequent,  and  in  a  few  hours  the 
catarrh  resolves  and  the  cough  becomes  lessened  in  fre(iuenc\- 
and  softer. 

Pain  upon  pressure  oi'cr  flic  region  of  the  larynx  is  more 
•developed  during  true  croup,  a  more  pronounced  cyanosis  sets  in, 
as  well  as  the  general  anaesthesia  (poisoning  with  CO.,). 

If  the  patient  is  old  enough  so  that  he  can  spit  out  the 
sputum,  then  the  examination  of  the  latter  may  furnish  the  most 
certain  tlata  for  the  diagnosis,  because  the  expectoration  of  false 
menihranes  positively  determines  true  croup,  but  a  contrary  con- 
clusion caiuiot  be  made,  as  not  every  patient  expectorates  portions 
of  membranes. 

As  in  the  majority  of  cases  croup  develops  during  diphtheria 
■of  the  fauces,  the  examination  of  the  throat  will  very  much  aid 
the  dia^iosis ;  in  false  croup  we  find  either  an  entirely  normal 
mucous  membrane,  or  a  slight  redness ;  however,  in  true  croup 
there  may  be  diphtheritic  patches  on  the  tonsils  or  on  the  soft 
palate,  as  well  as  on  the  posterior  wall  of  the  pharynx.  In  the  case 
-of  primary  croup,  that  is,  when  diphtheria  is  localized  from  the 
very  first  in  the  larynx,  avoiding  the  fauces,  the  diagnosis  very 
•often  may  be  made  from  a  bacterioscopic  examination  of  the 
mucus  taken  from  the  posterior  wall  of  the  pharynx ;  if  we  have 
here  a  diphtheritic  croup  then  almo.<t  always  Loffler's  bacillus 
will  be  found. 

Finally  the  history  in  doubtful  cases  may  be  of  decided  im- 
portance, because  false  croup  is  especially  inclined  to  occur  re- 
peatedlx'  in  the  same  person,  while  true  croup  never  occurs  re- 
peated) \    in  the  same  individual  :  so  that  if  it  l)c  kn(n\n  that  the 


266  DISEASES   OF   RESPIR.\TORV    SYSTEM 

patient  had  croup  before,  then  one  may  suppose  with  great  prob- 
abiHty  that  the  immechate  attack  is  a  false  one. 

We  have  thus  far  spoken  about  the  diagnosis  of  typical  cases- 
of  false  croup,  which  constitute  the  great  majority  ;  but  it  can- 
not be  doubted  that  there  are  severer  forms  of  laryngitis,  charac- 
terized by  a  longer  period  of  stenosis,  which  may  lead  the  patient 
to  asphyxia  and  death  from  suffocation,  despite  the  complete 
absence  of  a  fibrinous  exudation  in  the  larynx.  Such  laryngitis 
is  marked  by  considerable  swelling  of  the  mucous  membrane  an'/ 
the  submucous  tissue  of  the  whole  larynx,  and  especially  of  tht 
epiglottis  and  lig.  aryepiglot..  is  sometimes  described  as  laryn- 
gitis siihiiiucosa.  arising  either  from  cold,  and  then  it  differs  from 
a  true  croup  by  the  rapid  onset  of  a  considerable  stenosis ;  or  after 
soiue  infectious  diseases,  especially  in  smalljiox  and  measles,  or 
under  the  influence  of  trauma  (foreign  bodies  in  the  larynx,  burns 
from  boiling  water). 

The  dififerential  diagnosis  of  such  laryngites  from  croup  is 
possible  only  with  the  aid  of  the  laryngoscope.  Hacteriologic 
data  alone  are  positively  insufficient  for  this  ])urpose,  because 
it  is  admitted  that  croupous  inflammation  of  the  mucous  mem- 
brane in  general,  and  of  the  larynx  especially,  is  by  no  means 
caused  by  the  di])htheritic  poison  alone,  but  may  arise  also  from 
other  sources.  \\'e  may  here  refer,  for  instance,  to  non-contag- 
ious, or  the  so-called  sporadic  crouj).  lar\ngitis  in  some  cases  of 
measles  (the  secondar\'  crouj).  according  to  Rilliet  and  Rarthez),, 
artificial  laryngeal  crou])  in  animals,  caused  bv  burning  with  am- 
monia fluid,  etc.,  so  that  absence  of  Loffler's  bacillus  does  not 
exclude  croup. 

Great  resemblance  to  croup  may  also  be  presented  by  cases 
of  CEDEMA  LARYNGis.  The  diagnosis  here  is  based  especially  on 
the  fetiology  of  the  given  disease  and  on  the  rapiditv  of  develop- 
ment of  symptoms  of  stenosis. 

QEdema  laryngis  develops  under  the  influence  of  hydraemia 
in  diseases  of  the  kidneys,  constituting  then  only  a  part  of  the- 
general  dropsy,  in  which  condition  the  cause  of  stenosis  may  be 
easily  recognized.  Sometimes,  although  very  seldom,  it  happens 
that  cedema  of  the  larynx  appears  as  the  first  symptom  of  dropsy 
and  the  diagnosis  in  such  a  case  cannot  be  made  without  an  ex- 
amination of  the  urine. 


Disi-:.\si':>  OF  Ki-:si'iK A  roKN'  svs  ri-:M  2(>y 

In  otlicr  instances,  cL'dcma  of  the  glottis  ooniplicalt-^  severe 
inllanmialory  processes  in  neighboring  organs,  for  example,  in 
angina  Ludovici.  phlegmonous  tonsillites,  retro-])harvngcal  ab- 
scesses, as  well  as  ulcerous  processes  in  the  larynx  itself  (syphilis, 
tuberculosis),  and  perichondritis  in  acute  cases  (scarlatina,  small- 
pox, tyi)hoid)  and  in  chronic  ones  (syphilis,  lubcrcuhjsis j. 

Besides  the  aetiology  in  the  diagnosis  of  uedema  glottidis,  or 
of  lar\ngitis  submucosa,  one  may  also  use  data  obtained  from 
inspection  ;  by  strong  pressure  on  the  base  of  the  tongue  it  is  often 
possible  to  see  the  considerably  thickened  and  deformed  epiglottis, 
and  pali)ating  the  entrance  of  the  larynx  with  the  finger  one  may 
after  some  ]:)ractice  easily  reach  the  epiglottis  and  the  lig.  ar\epi- 
glottica. 

Stenosis  of  the  larynx  or  trachea  due  to  the  presence  of  a 
foreign  body  is.  usually,  prom])tl}"  recognized  from  the  historv ; 
the  child  w|iile  in  complete  health  was  playing  with  some  small 
objects,  and  suddenly  a  violent  attack  happened  ;  he  had  a  fit  of 
coughing  and  then  labored  breathing  began.  These  are  the 
characteristic  data  which  are  furnished  by  the  parents.  If  the 
history  is  absent,  or  is  very  scanty,  then  the  cause  may  remain 
undetermined.  In  the  case  of  a  foreign  body  stopping  at  the  en- 
trance of  the  larynx,  it  ma\-  be  felt  by  the  finger  and  even  ex- 
tracted (I  would  like  to  point  out,  by  the  way,  that  in  all  cases  of 
acute  development  of  stenosis  in  children  one  should  resort  to 
examination  of  the  accessible  ])ortions  of  the  pharxnx  and  larvn.x 
with  the  finger.  This  is  the  most  certain  method  of  determining 
retro-pharyngeal  abscess,  but  besides  this  it  may  serve  for  the 
diagnosis  of  redema  glottidis  and  of  the  presence  of  foreign 
bodies). 

Should  it  happen  that  a  foreign  body  reaches  the  trachea 
one  nm\  sometimes  succeed  in  feeling  its  crowding  movements 
by  palpation  of  the  neck  (external  surface)  during  coughing.  If 
the  foreign  body  has  sunken  still  more  and  lodged  in  one  of  the 
main  bronchi,  then  a  weakened  respiration  is  obtained  in  the 
corresponding  lung. 

Attacks  of  suffocation  may  also  be  produced  by  a  foreign 
botly  (a  piece  of  food)  stopping  in  the  upper  third  of  the  oeso- 
phagus.    This  is  usually  determined  b}-  the  history. 

Stenosis  of  the  larynx  because  of  spasm  of  the  nuiscles  ivhieh 


268  DISEASES   OF   KESPIKATnRV    SYSTEM 

narroii'  tJic  glottis — spasm  glottidis,  although  it  may  not  lead  to 
death  from  suffocation,  nevertheless  the  picture  of  the  disease 
does  not  resemble  croup,  neither  does  it  resemble  stenosis  caused 
by  a  foreign  body.  Spasm  of  the  glottis,  as  well  as  the  latter 
cause,  is  characterized  by  s}-mptoms  of  suffocation  suddenly  ap- 
pearing in  a  child  in  complete  hcallh,  but  spasm  appears  in  con- 
ditions which  exclude  any  supposition  of  a  foreign  body.  The 
attack  sets  in  either  during  the  cry,  or  when  the  child  is  resting 
in  the  mother's  arms  and  not  playing  with  any  small  t6ys,  etc. 
The  child  makes  a  whistling  inspiration  and  then  suddenly  stops 
breathing,  his  face  becomes  cyanotic,  he  suft'ocates  and  finally 
general  convulsions  come  on  (twitching  of  the  facial  muscles, 
rolling  of  the  eyes,  convulsive  stretching  of  the  extremities).  The 
attack  of  apncea  lasts  only  a  few  seconds,  and  then  the  child 
begins  to  breathe  freely,  that  is,  without  stenotic  inspiratory  noise, 
but  remains  for  a  while  weak  and  somnolent.  If  the  spasm  is  so 
violent  that  it  does  not  pass  off  innnediately,  then  the  child  after 
one  or  two  minutes  will  die  from  suffocation. 

It  follows  that  spasm  of  the  glottis  diff'ers  from  laryngeal 
stenosis  due  to  other  causes  by  the  sudden  onset  of  apniva  {zvithoiit 
any  cause,  or  under  the  influence  of  some  psychical  excitement), hy 
its  very  short  duration  and  by  the  loud  zvhistling  sound  duri)ig  in- 
spiration at  the  I'cry  onset  of  the  attack  or  at  its  end. 

As  spasm  of  the  glottis  is  produced,  so  to  say,  by  intern.-^l 
causes,  that  is,  as  it  depends  upon  a  peculiar  irritability  of  the 
medulla  oblongata,  under  the  inlluence  of  general  malnutrition 
of  the  organism  and  especially  of  rachitis,  it  never  happens  that 
such  a  cause  will  produce  only  a  single  attack ;  on  the  contrary, 
laryngismus  stridulus  is  inclined  to  relapses.  The  paroxysms 
are  at  the  beginning  not  severe  and  suddenly  pass  away,  accom- 
panied only  by  a  single  crowing  inspiration  without  interruption 
of  the  respiration  (incomplete  closure  of  the  glottis).  After  some 
time  such  alx>rtive  paroxysms  are  replaced  by  severer  attacks, 
manifested  by  cessation  of  breathing,  loss  of  consciousness  and 
convulsions.  If  the  patient  does  not  die  during  one  of  such  parox- 
ysms, then  the  period  of  improvement  follows  in  the  form  of 
gradual  diminution  of  the  strength,  duration  and  frequency  of 
the  attacks.  The  course  usually  becomes  protracted  for  many 
weeks  and  even  months,  while  the  duration  of  free  intervals  be- 


DISEASES   OF   RESTIRATORY   SYSTEM  269 

tween  separate  attaeks  varies  greatly  from  a  few  minutes   (ten 
to  thirty  attacks  a  day)  up  to  many  days. 

It  follows  that,  in  making'  the  diagnosis,  one  may  be  guided 
also  by  the  attacks  being  repeated,  by  the  general  condition  of 
niiirition  and  tJie  age  of  tlic  child. 

Laryngismus  stridulus  (laryngo-spasmus)  always  begins  dur- 
ing the  first  year  of  life  and  seldom  continues  beyond  one  and  one- 
half  years  ;  thus  its  greatest  maximum  coincides  with  the  period 
of  first  dentition.  It  almost  exclusively  afi:'ects  rachitic  children 
and  especially  those  suffering  with  craniotabes  (softening  of  the 
occiput).  But  this  does  not  mean  that  laryngismus  stridulus 
depends  upon  the  softened  occiput ;  the  connection  between  these 
two  morbid  processes  must  be  understood  to  be  that  both  depend 
upon  rachitis. 

[That  spasm  of  the  glottis  may  be  caused  by  adenoid  vege- 
tations was  pointed  out  in  the  note  to  page  256. — Earle.] 

Difficult  breathing  due  to  stenosis  of  the  fauces,  for  instance 
during  phlegmonous  sore  throat,  may  sometimes  indeed  reach 
a  considerable  degree,  but  the  voice  in  such  cases  becomes  only 
nasal,  and  not  harsh  ;  cough  is  absent,  but  there  is  a  severe  pain 
on  deglutition ;  so  that  these  symptoms  alone  may  show  that 
the  disease  is  not  located  in  the  larynx,  but  in  the  fauces,  the 
inspection  of  which  is  sufficient  to  make  the  diagnosis. 

Retro-pharyngeal  abscesses  {abscessus  retro-pharyngeus) 
are  frequently  overlooked.  For  this  reason,  and  likewise  because 
this  disease  very  often  exists  in  childhood  and  especially  in  nurs- 
lings, I  shall  describe  it  somewhat  minutely. 

There  are  two  kinds  of  retro-pharyngeal  abscesses  in  chil- 
dren: acute,  or  idiopathic,  caused  by  suppurative  inflammation 
of  the  lymphatic  glands  imbedded  in  the  mucous  membrane  of  the 
posterior  pharyngeal  wall;  and  the  chronic  (burrowing)  variety 
which  accompanies  caries  of  the  vertebrae. 

Abscesses  of  the  former  group  are  peculiar  especially  to 
nurslings,  and  occur  quite  often ;  the  latter  belong  to  the  rarer 
appearances,  never  occurring  in  nurslings. 

In  the  beginning  of  the  disease  the  symptoms  are  not  char- 
acteristic at  all :  the  first  thing  the  mothers'  notice  is  harsh  breath- 
ing during  sleep.  With  the  abscess  already  developed  it  is  not 
difficult  to  recognize  the  condition  ;  the  patient  is  in  the  state  of 


2/0  DISEASES   OF   RESPIRATORY    SYSTEM 

severe  d\*spnoea  with  depression  of  the  yielding  portions  of  the 
chest  during  each  inspiration.  A  great  similarity  exists  in  this 
regard  between  croup  and  this  disease.  A  marked  difference, 
however,  may  be  noticed  between  them  in  two  features :  fir.st, 
there  is  absence  of  the  stenotic  respiratory  sound  which  is  so 
characteristic  of  croup  (false  or  true,  it  is  immaterial),  and  which 
is  always  present ;  and,  second,  there  is  absent  the  ringing  cough 
as  well  as  the  harsh  voice.  While  inspiration  is  also  accompanied 
by  a  noise  in  the  case  of  abscess,  yet  this  noise  is  an  entirely  differ- 
ent one,  as  it  resembles  moist  snoring,  being  more  in  evidence 
during  sleep.  The  voice  also  becomes  changed ;  it  assumes  the 
nasal  twang,  but  aphonia  is  absent.  A  similar  tone  of  voice  may 
be  produced  artificiall\-  if  the  throat  be  compressed  between  the 
ascending  l)ranch  of  the  inferior  maxilla  and  the  upper  end  of 
the  sterno-cleiflo-mastoid  muscle  (  l*>okaj).  Cough  is  either  en- 
tirely absent,  or  it  is  slight  and  does  not  exhibit  any  peculiarities ; 
it  is  only  important  in  the  diagnosis  that  the  cough  is  ringing. 
Pain  on  swallowing  may  be  noticed  from  the  very  first,  increasing 
according  to  the  enlargement  of  the  abscess,  and  during  the 
period  of  its  complete  development  it  may  happen  that  the  child 
refuses  food  and  drink  altogether — in  croup  we  do  not  see  any- 
thing like  this. 

Further,  the  habitus  of  the  patient  is  characteristic ;  the  head 
is  somewhat  thrown  back,  or  bent  toward  the  more  affected  side 
(torticollis).  The  head  is  fixed  and  there  is  a  tumor  of  the  neck 
under  the  angle  of  the  inferior  maxilla  (this  tumor,  however, 
is  not  always  present,  but  swollen  glands  may  at  least  be  pal- 
pated). If  with  these  symptoms  the  presence  of  a  retro-pharyn- 
geal  abscess  may  be  suspected,  then  one  should  not  conclude  that 
a  final  diagnosis  may  be  made  by  mere  inspection  of  the  throat. 
On  the  contrary,  this  is  the  reason  that  abscess  of  the  posterior 
wall  of  the  pharynx  often  remains  unrecognized,  physicians  con- 
tenting themselves  with  inspection  alone.  The  main  thing  is  that 
in  such  a  patient  deglutition  is  difficult,  therefore,  there  is  always  a 
great  accumulation  of  mucus  in  the  throat,  which  considerably 
prevents  the  examination  thereof.  Even  in  a  normal  condition  it 
is  difficult  to  inspect  the  throat  in  nurslings.  In  order  not  to  over- 
look a  retro-pharyngeal  abscess,  one  should  therefore  observe 
the  rule  to  examine  the  throat  in  all  doubtful  cases  and  feci  the 


disi-:ases  t)F  RKSpjKAioKv  svsii:.\[  27X 

posterior  wall  of  the  pharynx  with  the  finger.  As  soon  as  an  ab- 
scess exists  there,  then  it  is  readilx-  felt  as  a  smooth,  elastic,  iluctu- 
ating-  tumor  located  on  the  posterior  wall,  usually  somewhat  lat- 
erally from  the  median  line. 

A  further  difiference  as  to  croup  lies  also  in  the  course.  Croup 
produces  laryngeal  stenosis  comparatively  early,  in  about  three  or 
four  days,  while  retropharyngeal  abscess  develops  slowly,  so  that 
from  ten  to  fourteen  days  elapse  from  the  time  of  the  appearance 
of  harsh  respiration  during  sleep  up  to  the  period  of  considerable 
stenosis,  while  about  five  or  ten  days  are  occupied  by  the  period 
of  progressive  increase  of  the  stenosis.  How^ever,  deviations 
from  these  average  periods  occur  not  infrequently ;  for  instance, 
cases  of  formation  of  an  idiopathic  abscess  in  two  or  three  da}S 
have  been  seen  (Bokaj)  and,  on  the  other  hand,  there  have  been 
cases  of  five  or  eight  weeks'  duration,  and  accordingly  some 
authors  distinguish  acute,  subacute  and  chronic  idiopathic  retro- 
pharyngeal abscesses. 

Fever  is  of  no  value  in  the  diagnosis :  it  may  be  absent  in  the 
beginning,  but  in  the  period  of  suppuration  the  temperature  nec- 
essarily rises  to  39  degrees  C.  (102.2  degrees  F.)  with  great  morn- 
ing remissions. 

It  is  not  difficult  to  distinguish  an  idiopathic  abscess  from  a 
burrozi'iiig  one,  because  in  the  latter  form  symptoms  of  cervical 
spondylitis  must  be  decidedly  pronounced,  as  well  as  the  chronic 
■course  of  the  disease  (see  spondylitis). 

In  small  chihiren  who  cannot  breathe  through  the  mouth, 
syinptODis  of  stenosis  of  the  upper  respiratory  passages  (infre- 
quent respiration  with  depression  of  the  yielding  portions  of  the 
chest,  but  without  the  characteristic  stenotic  inspiratory  noise) 
may  appear  under  the  influence  of  a  common  rhinitis.  In  such 
■cases  the  most  important  distinctive  symptom  will  be  that  during 
crying  the  labored  respiration  disappears  immediately. 

In  exceptional  cases  something  similar  occurs  also  in  older 
children.  A  boy  aged  eight  years  of  age  became  ill  in  the  beginning 
of  November,  1888,  with  a  severe  rhinitis  and  cough  (la  grippe), 
and  on  November  10,  under  the  influence  of  a  beginning  menin- 
gitis, he  became  very  somnolent,  and  there  apjieared  a  very  labored 
respiration  ;  this  was  retarded,  and  during  each  inspiration  there 
Avas  noticed  depression  not  only  of  the  intercostal  interspaces,  but 


272  DISEASES   OF   RESPIRATORY    SYSTEM 

also  of  the  lower  portion  of  the  sternum,  and  of  the  supra-clavi- 
cular and  jugular  fossse;  in  short,  as  if  there  was  a  fully  developed 
croup.  But  the  voice  remained  clear  all  the  time,  therefore  the 
cause  of  the  stenosis  had  to  be  looked  for  elsewhere  outside  of 
the  larynx  (viz,  outside  of  the  glottis).  Retro-pharyngeal  ab- 
scess also  could  be  excluded.  Further  examination  showed  that 
the  patient's  tongue  was  drawn  far  back,  its  tip  pressed  toward 
the  hard  palate,  so  that  the  air  supply  through  the  mouth  was 
prevented ;  moreover,  the  nose  was  blocked  up  from  snuffles,, 
hence  the  result — symptoms  of  severe  stenosis  of  the  upper  respir- 
atory passages.  One  had  only  to  open  the  patient's  mouth  and 
depress  the  tongue  with  a  spoon,  when  the  respiration  became 
entirely  free.  Similar  stenosis  may  be  produced  experimentally 
by  anyone  on  himself;  it  is  necessary  only. to  throw  the  tongue 
backwards,  compress  the  nose  and  try  to  catch  the  breath.  It  is 
obvious  that  had  our  patient  not  been  under  the  influence  of 
meningitis,  in  a  somnolent  condition,  he  could  have  removed  the 
obstacle  and  breathed  through  the  mouth. 

To  the  same  class  of  cases  also  belongs  the  groaning  respira- 
■tion  of  children  of  the  first  months  of  life,  which  depends,  ac- 
cording to  Politzer,  who  first  described  such  a  breathing,  upon 
abnormal  innervation  of  the  soft  palate.  With  more  advanced 
age,  for  instance,  toward  the  end  of  the  year,  such  a  groaning 
respiration,  or  snoring,  disappears  of  itself  and  the  breathing 
becomes  normal,  soundless. 

CHRONIC  STENOSIS  OF  THE  UPPER  RESPIRATORY 

PASSAGES. 

Causes  of  chronic  stenosis  of  the  upper  respiratory  passages- 
mav  manifest  themselves  either  in  the  larynx,  or  in  the  trachea. 
In  the  former  case  the  voice  will  necessarily  be  changed,  becoming 
either  harsh,  or  aphonic  altogether ;  in  the  latter  case  it  remains- 
clear  or  changed  but  little  (because  of  accompaning  slight  catarrh 
of  the  larynx).  The  degree  of  stenosis  in  laryngeal  affections 
may  be  of  all  gradations,  not  excepting  even  the  severest  form ; 
in  tracheal  stenosis  its  degree  does  not  go  be3-ond  the  middle  form,, 
that  is,  the  patient  can  compensate  the  sequelae  of  the  stenosis  by 
means  of  increased  activity  of  the  inspirations. 

Chronic  stenosis  of  the  larynx  in  children   most  often  de- 


DISEASES   (IE    RES1'1RAT()K^■    SYSTEM  2/3 

peiuls  upon  svimiilis.  namely,  upon  coiidyloinatons  proliferations 
of  the  laryngeal  iiiiic(Uis  membrane;  in  rarer  cases  upon  tubercu- 
losis or  tumors  of  the  larynx. 

If  the  history  be  known,  or  if  the  patient  presents  apj^arent 
symptoms  of  syphilis,  then  the  diagnosis  is  not  difficult ;  but  if  the 
aflfection  of  the  larynx  is  the  single  manifestation  of  syphilis  at 
the  given  time  (this  appears  not  very  seldom),  then  the  diag- 
nosis may  exhibit  some  difficulties.  It  is  important  in  the  diag- 
nosis that  the  favorite  place  for  the  development  of  condylomata 
is  the  epiglottis,  which  often  may  be  seen  by  depressing  the  base 
of  the  tongue,  especially  during  the  nauseous  movement  pro- 
duced by  the  examination  ;  it  appears  then  as  a  deformed,  thick- 
ened, small,  hollow  cylinder  of  whitish-red  color.  It  is  still  better 
if  the  patient  can  be  examined  laryngoscopically,  even  for  one 
moment ;  the  aspect  of  condylomata  is  so  characteristic  that  it 
does  not  require  a  prolonged  inspection.  However,  the  diag- 
nosis is,  in  the  majority  of  cases,  possible  even  without  the  lar- 
yngoscope. As  the  larynx  is  never  the  place  of  the  first  appear- 
ance of  secondar}'  syphilitic  symptoms,  on  the  contrary  becoming 
involved  during  relapses ;  then  by  inspecting  the  whole  surface 
of  the  body  one  usually  succeeds  in  detecting  elsewhere,  most  often 
in  the  anal  region,  traces  of  an  old  syphilis  in  the  form  of  reddish 
spots  or  scars  in  the  place  of  old  condylomata,  as  well  as  thicken- 
ing of  the  mucous  membrane  in  the  corners  of  the  mouth.  These 
are  especially  characteristic,  if  whitish  in  color.  Remains  of 
condylomata  may  also  occur  in  the  throat,  particularly  on  the 
soft  palate.  (More  minutely  about  the  retrospective  diagnosis 
of  sypliilis  see  the  section  on  Syphilis.)  The  history  shows  that 
the  Ciiild's  mouth  was  formerl}'  affected  and  there  were  wet 
places  around  the  anus ;  that  the  mother  had,  perhaps,  many 
children,  but  they  died  soon  after  birth  ;  that  some  of  them  were 
still-born,  or  even  abortion  had  occurred.  As  I  have  said,  the 
larynx  becomes  involved  only  during  relapses  and  very  lately, 
therefore  almost  never  in  nurslings.  Most  often  we  obsen-e 
sy])hilis  of  the  larvnx  in  children  from  two  up  to  seven  years 
of  age. 

Gummata  and  ulcers  occur  in  the  larynx  less  often  than 
condylomata.  Their  diagnosis  is  impt^ssible  without  the  Iar\ngo- 
scope. 


274  DISEASES   OF   RESPIRATORY    SYSTEM 

I'libercular  ulcers  in  the  trachea  and  larynx  occur  very  sel- 
dom in  children,  especially  in  those  under  seven  years,  although 
cases  of  tubercular  ulcer  of  larynx  even  in  small  children  are  re- 
ported in  literature,  for  instance,  Rheindorff's  patient  was  only 
nine  months  old  when  hoarseness  and  cough  appeared,  being  the 
first  symptoms  of  tuberculosis  of  the  larynx,  which  was  proven 
by  post-mortem  in  the  fourteenth  month  of  life. 

Symptoms  of  laryngeal  stenosis  because  of  tubercular  ulcers 
occur  very  rarely;  in  the  overwhelming  majority  of  cases  there 
are  to  be  observed  only  a  harsh  voice  and  cough.  The  diag- 
nosis of  tuberculosis  of  the  larynx  may  be  assisted  by  such 
patients  exhibiting  apparent  symptoms  of  tuberculosis  of  the 
lungs. 

Chronic  stenosis  of  the  larynx  may  also  be  produced  by  new 
GROWTHS,  which  in  childhood  must  be  referred  almost  exclusively 
to  papillomata.  Regarding  the  diagnosis  it  is  important  to  notice 
that  in  the  great  majority  of  cases  they  are  inherited,  therefore 
this  cause  of  stenosis  may  be  suspected  only  if  development 
occurs  very  slowly  in  a  child  previously  in  good  health,  m  whom 
neither  syphilis  nor  tul^erculosis  may  be  suspected,  and  if  the  first 
symptoms  of  the  affection  of  the  larynx  in  the  form  of  hoarseness 
or  complete  aphonia,  and  later  on  in  the  form  of  a  rough  cough,  ap- 
peared during  the  first  days  of  life  or,  at  least,  during  the  first 
year. 

Perichondritis  laryngea  almost  never  occurs  as  an  inde- 
pendent or  primary  lesion,  but  always  after  some  general  acute 
or  chronic  diseases.  In  childhood  this  morbid  form  has  been 
observed  after  typhoid  fever,  smallpox,  scarlet  fever,  (the  case 
of  Jacubovich*  of  a  girl  of  one  year  and  eight  months  old  is  inter- 
esting by  stenosis  of  the  larynx  having  developed  so  quickly  that 
the  diagnosis  of  diphtheria  w^as  made  during  life),  but  oftener 
in  syphilis  and  tuberculosis,  although  generally  very' rarely.  As 
perichondritis  is  usually  associated  with  ulcerous  processes  the 
patient  manifests  various  symptoms  of  severe  laryngitis  long  be- 
fore its  real  appearance.  One  may  suppose  the  development  of 
perichondritis  in  a  case,  if,  in  the  presence  of  certain  aetiological 
factors  the  patient  complains  of  pain  in  a  certain    part    of    the 


*Arch.  f.  Kiiidcrh.  X.  B.  I.  35. 


DISEASES    OF   RESiMRA  I'URY    SYSTEM  2/5 

lannx,  increasing-  upon  pressure,  and  if  outward  swelling;  of  iIk- 
cervical  cellular  tissue  corresponds  to  the  place  of  pain. 

In  countries  where  struma  prevails  endeniically  the  cause  of 
chronic  stenosis  of  the  trachea  is  tumor  of  the  thyrold  gland, 
but  in  our  locality  the  trachea  becomes  much  more  often  c6m- 
pressed  at  the  point  of  its  bifurcation  by  enlarged  and  caseously 
degenerated  lymphatic  glands. 

It  is  easy  to  recognize  compression  of  the  trachea  due  to 
struma,  as  a  tumor  on  the  anterior  surface  is  noted  at  first  glance. 

Hyperplasia  and  caseous  degeneration  of  the  bronchial 
GLANDS,  compressing  the  trachea  at  its  bifurcation,  may  be  rec- 
og-nized  partly  by  excluding  other  causes  of  stenosis,  partly  on  the 
ground  of  positive  data  and  the  history. 

Tlie  history  shows  that  the  patient  suffers  with  cJironic  sten- 
osis of  the  upper  respiratory  passages  and  that  this  stenosis  de- 
veloped very  slowly.  It  may  be  found  that  labored  breathing 
at  the  beginning  appeared  only  for  a  short  period,  during  in- 
crease of  the  cough,  and  in  slight  degree ;  later  on,  the  stenosis 
would  disappear  to  reappear  after  a  short  interval,  until  it  finally 
became  constant,  although,  perhaps,  not  to  a  considerable  degree. 
The  patient  suft"ers,  besides  this,  with  chronic  cough,  being  either 
scrofulous  or  rachitic ;  his  voice  is  entirely  clear  and  the  larynx  is 
thus  not  involved. 

On  the  basis  of  these  data  one  may  suppose  with  great  prob- 
ability that  the  stenosis  is  in  the  trachea,  being  dependent  upon 
enlarged  glands.  In  favor  of  the  latter  proposition  there  is  the 
general  condition  of  nutrition  of  the  patient  (scrofulosis  and 
rachitis)  and  chronic  catarrh  of  the  respiratory  organs,  which  is 
never  absent  in  such  patients. 

The  minute  examination  of  the  patient  will  bring  out 
still  other  data.  At  the  point  of  stenosis  mucus,  which 
causes  the  harsh  breathing,  frequently  accumulates.  This  sound, 
resembling  either  ronchus  sonorous  or  large,  bubbling  rales  is 
heard  all  over  the  chest  (conducted  rattle),  but  it  is  loudest  on  the 
manubrium  or  between  the  scapulae  in  the  upper  portion  of  tlu- 
chest;  one  may  also  feel  it  by  palpating  here.  This  rattle  may 
sometimes  be  heard  for  many  weeks  in  succession,  but  not  always 
equally  well;  sometimes  it  disappears  altogether,  again  it  in- 
creases, especially  during  any  excitement  of  the  child.     If   the 


2/6  DISEASES    OF    Ui:S[MRAT()RV    SYSTEM 

glands  are  so  large  that  the  whole  space  between  the  bifurcation 
of  the  trachea  and  sternum  is  filled,  then  they  serve  as  a  good 
conductor  of  the  respiratory  murmur,  therefore,  bronchial  breath- 
ing or,  at  least,  a  loud  respiration  may  be  heard  on  auscultation, 
in  the  first  intercostal  space,  near  the  sternal  margin  in  the  area 
of  the  involved  glands.  In  estimating  this  symptom  one  should 
bear  in  mind  that  on  the  right  side  (the  right  bronchus  is  wider 
than  the  left)  tubular  respiration  not  infrequently  is  heard  even  in 
the  normal  condition,  so  that  loud  expiration  may  be  of  decided 
importance  in  favor  of  enlargement  of  the  tracheal  glands  only 
if  on  the  left  side  it  is  either  very  pronounced,  or  louder. 

Percussion  sometimes  (although  seldom)  gives  some  dull- 
ness on  both  sides  of  the  sternum  in  the  first  and  second  inter- 
costal spaces,  or  at  the  point  of  the  sterno-clavicular  articula- 
tion ;  in  other  cases  dullness  on  the  back  between  the  scapuhe  may 
be  noted,  along  the  sides  of  the  first  three  spinal  vertebrae.  If 
dullness  be  obtained  only  on  the  sternum  upwards,  then  it  may 
depend  upon  the  thymus,  and  the  younger  the  child  the  more 
probable  is  this  cause.  In  children  five  or  six  years  of  age  the 
presence  of  the  thymus  does  not  usually  manifest  itself  by  a 
dull  sound.  In  small  children  the  dull  sound  dependent  upon  the 
thvmus  either  does  not  pass  beyond  the  margin  of  the  sternum 
altogether,  or  extends  on  one  or  the  other  side  not  more  than 
one-half  of  a  centimeter.  In  the  case  of  enlargement  of  the  thy- 
mus a  dull  sound  will  be  especially  expressed  over  the  sternum 
itself,  but  not  in  the  intercostal  spaces,  as  in  hyperplasia  of  the 
glands. 

Furthemiore,  symptoms  may  be  present  which  point  toward 
compression  of  the  venous  vessels  (oedema  or  puffiness  of  the 
face,  distension  of  the  jugular  veins)  or  of  the  pneumogastric 
or  the  recurrent  nerves  (convulsive,  pertussis-like  cough,  but 
usually  without  the  whistling  inspiration,  change  of  the  voice, 
asthma) . 

Stenotic  s}-mptoms  may  be  highly  characteristic  even  by 
themselves,  namely,  if  one  of  the  main  bronchi  is  compressed, 
with  symptoms  of  the  sequelae  of  stenosis,  that  is,  symptoms  of 
insufficient  access  of  air  to  the  lungs,  manifesting  themselves 
only  pn  the  part  of  the  chest.  These  symptoms  consist  in  that  the 
corresponding  half  of  the  chest  dilates  during  inspiration   less 


DISEASES    OF   RESI'l  RA1'(  )RV    SVS'lEM  277 

than  the  other,  whiK-  (k'])rcssi()n  of  the  yickhiii;"  portions  is 
greater.  At  the  same  place  a  weakened  resjMratory  murmur  may- 
be noticed  and  feehk'  vocal  fremitus,  the  ])ercussion  note  being 
normal. 

k\>ver  in  hxperplasia  of  the  bronchial  glands  may  be  absent, 
but  as  considerable  enlargement  of  the  glands  is  usually  observed 
in  tuberculous  children  (although  the  lungs  ma\-  be  free  from 
tubercles),  the  elevation  of  temperature  is  seldom  absent,  so 
that  an  miaccoiiiifahlr  fc'i'cr  obscrr'cd  in  a  child  may  considerably 
confirm  the  diagnosis  of  tuberculosis  of  the  glands,  especially  in 
case  it  became  protracted  after  some  disease  which  was  compli- 
cated by  bronchitis  (la  grippe,  measles,  whooping-cough).  It 
is,  of  course,  obvious  that  even  in  such  an  instance  a  mistake  is 
possible.  For  instance,  in  one  case  I  made  an  erroneous  diag- 
nosis of  tuberculous  hyperplasia  of  the  bronchial  glands  on  the 
ground  that  stenosis  of  slight  degree  ( noticeable,  however,  also 
during  quiet  respiration)  appeared  in  a  girl  four  years  old  who 
had  suffered  a  long  time  with  bronchitis  ;  afterwards  the  cough 
almost  disappeared,  but  moderate  fever  (about  38  degrees  C. — 
100.4  degrees  F.  in  the  morning,  and  38.5  degrees  C. — 101.3  de- 
grees F.  in  the  evening)  was  persistent  during  an  entire  month. 
As  the  girl  had  rhinitis  at  the  same  time,  a  specialist  in  nose 
and  throat  diseases  was  consulted.  The  laryngoscopic  examina- 
tion showed  that,  despite  the  clear  voice,  the  place  of  narrowing 
was  in  the  larynx  and  was  dependent  upon  a  spasmodic  condi- 
tion of  the  muscles  closing  the  glottis,  so  that  during  inspiration 
the  vocal  cords  did  not  separate  suf^cientl\ ,  and  the  avenue  for 
the  passage  of  air  was  narrowed. 

Such  a  condition  of  the  vocal  cords  was  produced,  undoubt- 
edly, by  a  reflex  action  from  the  mucous  membrane  of  the  nose, 
the  local  treatment  of  which  ]:)roduced  complete  iecover_\-  of  the 
patient.  I  do  not  know  whether  such  neuroses  belong  to  the 
rarities  or  not. 

Prof.  Franz  Mayr*  sums  up  the  diagnosis  of  hyperplasia 
of  the  bronchial  glands  in  the  following  way:  Aside  from  the 
results  of  percussion  and  auscultation  we  may  suspect  this  disease : 

(i)      If  a  child  with  hereditary  predisposition  to  tuberculo- 

'*Jalirb.  f.  Kiinli'ili.     1862.     Vol.  V. 


278  DISEASES    OF   RESPIRATORY    SYSTEM 

sis  or  scrofulosis  l>ecomes  afifected  with  an  obstinate  catarrh,  dur- 
ing which  there  appear  at  times  paroxysms  of  pertussis-Hke 
cough. 

(2)  If  the  same  appearances  are  noted  in  a  child  who  had 
suffered  previously  wath  rachitis  or  chronic  eczema  and  who  ex- 
hibits a  superfluous  growth  of  hair  on  the  temples,  posterior  part 
of  the  neck  and  the  back. 

(3)  If  the  child  is  repeatedly  subject  to  violent  and  contin- 
ued attacks  of  asthma ;  and,  finally, 

(4)  If,  in  a  child  three  or  four  years  old,  there  appear 
cough,  wasting,  fever  and  perspiration  without  any  symptoms  of 
tuberculosis  of  the  lungs,  brain  and  visceral  organs. 

Hyperplasia  of  the  bronchial,  as  well  as  of  any  other,  glands 
does  not  always  depend  upon  tuberculosis  (the  latter  is  only  the 
most  frequent  cause)  ;  but  may  also  arise  under  the  influence  of 
other  diseases  of  the  blood,  especially  syphilis  and  leukaemia.  If 
stenotic  respiration  appears  in  a  child  of  the  first  months  of  life, 
and  if  there  are  no  reasons  to  suppose  hyperplasia  of  the  bron- 
chial glands  ( ^etiological  factors  absent),  then  it  is  more  probable 
that  stenosis  of  the  trachea  depends  upon  an  enlarged  thymus. 
Such  stenoses  appear  from  the  first  days  of  life,  increase  at  times 
and  then  decrease  again,  disappearing  gradually  and  altogether 
during  the  second  year  of  life. 

Stenotic  respiration  due  to  chronic  lesions  producing  nar- 
rowing of  the  lumen  of  the  fauces  occurs  in  children  in  hypertro- 
phy of  the  tonsils.  The  access  of  air  to  the  lungs  may  then  be  so 
hindered  that  the  chest  remains  undeveloped,  assuming  the  form  olt 
"pigeon-chest,"  as  in  rachitis.  Usually  such  children  also  have 
adenoid  vegetations,  exhibiting  then  a  characteristic  habitus;  they 
are  pale,  keep  the  mouth  half  open,  the  voice  has  a  nasal  twang, 
and  the  nostrils  are  narrow.  During  sleep  they  snore  loudly. 
Inspection  of  the  fauces  detects  large  tonsils  the  tips  of  which 
sometimes  meet  each  otlier  in  the  median  line  of  the  fauces  and 
press  upon  the  uvula. 

One  must  add  that  drawing  in  of  the  lower  periphery  of  the 
chest  (that  is,  of  the  points  of  insertion  of  the  diaphragm)  dur- 
ing deep  inspiration  is  not  always  indicative  of  a  prevented  air- 
supply  to  the  lungs,  as  in  small  children,  three  or  four  months 
old,  such  a  depression   is  more  or  less  physiological,  persisting 


DISEASES    OF    RESPI RA  Tt  )KV    SVSri:.M  2/0 

in  rachitic  children  C(>nsi<kral)ly  longer.  It  (lf])fn(ls  merely  iipun 
soft  ribs,  which  do  not  make  a  snHicieiit  resistance  to  the  con- 
tracted diaphragm. 

In  small  children  who  cannot  breath  through  th.c  mouth, 
symptoms  of  stenosis  of  the  upper  respiratory  passages  may  ap- 
pear in  a  common  rhinitis.  In  such  cases  the  labored  breathinf; 
immediately  disappears  during  the  cr_\-. 

DISEASES  OF  THE  LUNGS  IN  WHICH  THE  PERCUS- 
SION SOUND  REMAINS  NORMALLY  CLEAR. 

Catarrh  of  the  respiratory  uranciies:  Broiichocataniiiis, 
s.  bronchitis. 

Symptoms  of  bronchitis  are  easily  ex])laincd  by  the  patho- 
logico-anatomial  changes  of  the  mucous  membrane  of  the  bron- 
chi. As  in  any  other  catarrh  we  here  meet  hypersemia  and  swell- 
ing of  the  mucous  membrane  with  increased  secretion  of  mucus, 
which  is  at  first  comparatively  scanty  and  transparent,  later  on 
more  abundant  and  yellowish. 

Irritation  of  the  mucous  membrane  in  catarrh  is  manifested 
by  cough,  which  is  the  necessary  and  frec[uently  the  chief  symp- 
tom of  any  bronchitis.  Regarding  other  symptoms  they  are  vary- 
ing, depending  upon  the  location  and  severity  of  the  disease,  and 
permit,  from  the  clinical  standpoint,  a  classification  of : 

( 1 )  Catarrh  of  the  trachea  and  the  first  respiratory 
branches. 

(2)  Catarrh  of  the  middle- bronchi,  and 

(3)  Capillary  bronchitis. 

All  these  kinds  of  catarrh  occur  in  the  acute,  as  well  as  in 
the  chronic,  form. 

The  diagnosis  of  bronchitis  is  not  usually  difficult ;  if  the 
patient  coughs,  his  voice  being  clear  (the  larynx  is  thus  not  af- 
fected), and  if  neither  dullness  nor  tympanitic  note  is  found  in 
the  Inngs,  then  we  have  either  a  tracheo-bronchitis,  or  a  pharyti- 
gitis.  If  the  posterior  wall  of  the  pharynx  be  normal  (redness  as 
well  as  granulations  absent),  if  rhinitis  be  absent  (cough  be- 
cause of  the  mucus  flowing  down  the  posterior  wall  of  the  phar- 
ynx), then  it  means  that  the  patient  suffers  with  catarrh  located 
below  the  vocal  cords.  If,  however,  some  changes  are  present 
peculiar   to  chronic   ])haryngitis,  so  that   it   is   impossible  to  ex- 


28o 


DISEASES    OF   RESPIRATORY    SYSTEM 


elude  this  eause  of  coughing,  then  it  would  be  illogical  to  diag- 
nose bronchitis  on  the  ground  of  a  mere  cough.  It  is  either  nec- 
essary that  the  patient  complain  of  a  feeling  of  soreness  ( irrita- 
tion) over  the  course  of  the  trachea,  or  that  he  expectorate 
sputum  (in  chronic  pharyngitis  the  cough  is  usually  dry),  or  that 
upon  auscultation  dry  or  moist  rales  be  heard  in  the  chest.  Espe- 
cially difficult  to  diagnose  are  cases  of  bronchitis  developing  dur- 
ing croup,  because  the  auscultatory  evidences  on  the  part  of  the 


Fig",  ig — Cast  in  croupous  brftuchitis,  natural  size   (Lenliartz). 

jjrunchi  and  lungs  are  entirely  deadened  by  the  stenotic  respir- 
atory murmtir  conducted  from  the  larynx.  It  is,  nevertheless, 
very  important  to  detect  bronchitis  during  croup,  for  deciding 
the  question  of  tracheotomy  and  for  the  prognosis  as  well.  As 
a  matter  of  fact,  bronchitis  arising  during  croup  is  usually  not  a 
catarrhal,  but  a  croupous  one  and  the  chances  for  recovery,  there- 
fore, decrease  considerably. 

If  the  croupous  process  is  limited  to  the  trachea — tracheitis 
crouposa — it  is  possible  to  recognize  this  complication  only 
after  tracheotomy,  namely,  in  case  the  patient  discharges  mem- 


DISEASES    OF   KESriRATUKV    SYSTEM  28r 

branes  throuj^di  tlic  lube.  From  the  aspect  of  the  membranes  one 
may  judg^e  of  the  degree  of  extension  of  the  process  and  decide 
if  only  the  trachea  is  involved  or  the  bronchi  as  well.  In  the 
former  case  common  membranes  are  expectorated ;  in  the  latter^ 
ramified  ones  (the  spututn  is  examined  in  such  case  under  water  K 
(Fig.  29.)  If  the  membranes  are  not  discharged,  then  one  may 
suppose  the  existence  of  croupous  bronchitis  only  in  a  case  wherein 
the  breathing  after  the  operation  remains  quickened  (in  children 
under  five  years  of  age,  more  than  forty  or  fifty ;  in  older  ones, 
thirty  or  forty)  and  fever  rises  higher  than  39  degrees  C.  (102.2 
degrees  ¥.).  Also  characteristic  is  the  complete  absence  of  cough 
during  the  first  hours  after  the  operation,  showing  tliat  the 
trachea  is  lined  with  membranes  and  therefore  is  not  sensitive  to 
irritation  by  the  tracheotomy  tube. 

In  view  of  what  has  been  said  one  may  exclude  croupous 
afl:ection  of  the  trachea  and  bronchi  if  the  patient  after  the  opera- 
tion does  not  cough  upon  ever}-  touch  of  the  tube  and  reacts 
strongly  upon  cleaning  the  tube  with  a  feather,  only  mucus  being 
discharged,  and  not  membranes;  and  if  the  respiration  after 
tracheotomy  becomes  almost  normal,  and  the  temperature  does 
not  rise  above  38.5  degrees  C.  (101.3  degrees  F.).  If  such  a  con- 
dition lasts  for  three  days  after  the  operation,  then  one  may  be 
sure  that  the  croupous  process  will  remain  localized  in  the  larynx. 

Before  operation  one  may  suspect  affection  of  the  bronchi 
if  the  patient,  notwithstanding  the  laryngeal  stenosis,  exhibits 
quickened  breathing,  and  if  attacks  of  CO2  poisoning  do  not  cor- 
respond to  the  degree  of  stenosis ;  that  is,  if  the  patient  becomes 
indifferent,  the  stenosis  being  inconsiderable,  his  extremities  be- 
come cool  and  cyanosis  appears.  The  rapidity  of  extension  of  the 
croupous  membranes,  and  the  temperature,  are  also  important  in 
the  diagnosis.  The  higher  the  fever  and  the  quicker  the  mem- 
branes spread  over  the  surface  of  the  throat  and  larynx,  the 
greater  the  cliances  are  that  the  process  will  not  be  limited  to  the 
larynx,  but  will  spread  lower. 

If  the  diagnosis  of  tracheitis  or  bronchitis  is  established, 
then  it  still  remains  to  decide,  first,  what  kind  of  catarrh  we  have 
to  deal  with,  that  is,  if  it  is  a  primary,  idiopathic  or  symptomatic 
one;  and,  second,  what  bronchi  are  aft'ected,  where  the  catarrh 
is  localized. 


282  DISEASES    OF   RESPIRATORY    SYSTEM 

The  answer  to  the  first  question  may  be  summed  up  thus : 
if  the  bronchitis  be  not  accompanied  by  symptoms  which  would 
admit  the  diagnosis  of  another  disease  (measles,  typhoid,  etc.), 
then  it  must  be  regarded  as  an  idiopathic  catarrh,  that  is,  an  in- 
dependent disease. 

Idiopathic  bronchitis  differs  generally  by  its  comparatively 
slight  course,  because,  in  children,  dangerous  capillary  bron- 
chitis almost  never  occurs  as  an  independent  disease,  appearing 
usually  as  a  consequence  or  a  symptom  of  la  grippe,  measles  and 
whooping-cough,  and,  in  chronic  cases,  of  rachitis. 

Cases  of  acute  idiopathic  bronchitis  usually  Ijegin  with  a 
more  or  less  considerable  fever  and  dry.  frequeiit  cough.  If  the 
patient  remains  within  doors  and  generally  is  not  exposed  to 
additional  noxious  influences,  then  the  period  of  resolution  very 
soon  sets  in ;  the  fever  disappears  after  three  to  five  days,  and 
the  cough  l>ecomes  less  frequent,  softer  and  more  moist,  and  after 
a  few  days  disappears  altogether. 

In  determining  the  location  of  the  catarrh  we  are  guided 
by  the  character  of  the  auscultatory  findings,  and  the  respiration 
as  well.  If  on  auscultation  large  rales  or  ronchi  sonori  be  heard, 
then  we  conclude  the  trachea  and  large  bronchi  are  involved,  as 
such  rales  may  be  formed  only  in  cavities  and  tubes  of  large  cali- 
ber. If  the  secretion  of  mucus  be  not  abundant  rales  may  be 
absent  altogether  in  tracheitis,  the  respiratory  murmur  remaining 
entirely  normal,  so  that  the  disease  in  the  beginning  manifests 
itself  only  by  cough  and  fever;  older  children  complain  also  of 
soreness  along  the  trachea. 

Cough  li'ithoiit  any  rales  in  the  chest,  in  the  absence  of  any 
percussion  signs,  may  depend  upon  chro)iic  pharyngitis,  which 
also  occurs  sometimes  in  childhood,  especially  in  scrofulous  and 
ansemic  children.  This  cause  of  cough  may  be  suspected  only  in 
such  cases  where  a  short,  dry  cough  (like  tickling  in  the  throat) 
is  persistent  in  a  child,  notwithstanding  he  is  kept  well  housed, 
and  if  no  rales  are  to  be  found  in  the  chest.  Inspection  of  the 
throat  reveals  that  the  posterior  wall  of  the  phar>'nx  is  red, 
marked  with  dilated  vessels  and  dry,  as  if  varnished.  Not  in- 
frequently there  appear  small,  flat,  oval,  pea-sized  elevations 
covered  with  the  same  mucosa  as  the  adjacent  parts — pharyngitis 


DISEASES   t)F    RESPIKATORV    SYSTEM  283 

grmnilosa.     A  persistent,  dry  cou^h   may  last  nianv  weeks  and 
•easily  recurs  on  the  slightest  cold. 

Here  it  is  also  well  to  mention  a  peculiar,  dry  cough  which 
arises  without  any  objective  signs  on  the  part  of  the  lungs,  lasts 
one  to  two  months,  differing  from  any  other  cough  by  bothering 
the  child  only  at  nights,  hence  the  name,  periodic  night  cough. 
The  cause  of  this  nervous  cough,  which  is  especially  peculiar  to 
irritable,  anaMiiic  children,  is  miknown.  It  sometimes  stops  quick- 
ly after  the  use  of  quinine,  therefore  one  ma}-  think  that  it  is 
a  symptom  of  febris  intermittens  larvata. 

If  medium-sized  bronchi  are  affected,  then  there  are  obtained 
either  rales  or,  in  the  case  of  scant  secretion,  coarse  vesicular 
-breathing  and  an  indefinite  respiratory  murmur,  or  a  weakened 
vesicular  breathing  because  of  narrowing  of  the  bronchi. 

In  CAPILLARY  BRONCHITIS  we  have  a  whistling  respiration 
as  an  indication  of  the  considerable  narrowing  of  the  lumen  of 
the  small  bronchi  because  of  swelling  of  their  mucosa;  later  on, 
in  the  period  of  formation  of  the  secretion,  small,  but  not  con- 
sonant rales  are  heard. 

Besides   these   signs,   capillary   bronchitis   differs    from   any 
■other  bronchitis  by  dyspiuva  which,  here,  is  never  absent.     Cap- 
illary bronchitis  is  always  bilateral,  and  the  catarrh  which  is  its 
•essence  is  of  the  diffuse  character,  that  is,  it  occupies  if  not  all,' 
then  almost  all,  bronchioles,  always  producing  narrowing  of  their 
lumen  and  thus  obstructing  the  air  supply  of  the  alveoli.    On  this 
account  every  inspiration  produces  rarefaction  of  the  air  in  the 
chest    (as  occurs   during  laryngeal   stenosis),   and  the   result   is 
drawing  in  of  the  yielding  portions  of  the  chest,  and  especially 
■of  its  lower  periphery  along  the  line  of  insertion  of  the  diaphragm. 
Thus,  inspiratory  dyspnoea  arises  which,  however,  is  not  difficult 
to  distinguish  from  inspiratory  dyspnoea  due  to  stenosis  of  the  up- 
per respiratory  passages.     During  the  latter,  first,  a  character- 
istic stenotic  murmur  always  may  be  heard,  while  in  capillary 
"bronchitis  the  same  is  absent ;  second,  the  respiration  in  stenosis 
is  of  normal  rate  or  even  somewhat  retarded,  while  in  capillary 
bronchitis  it  is  considerably  accelerated   (in  children  under  two 
years,  from  seventy  up  to  one  hundred  per  minute)  and  becomes, 
■of  course,  very   shallow.     There   is  also  some  difference  to  be 
•aioticed  in  the  action  of  the  respiratory  muscles ;  the  neck  muscles 


284  DISEASES   OF   RESPIRATORY    SYSTEM 

(scaleni)  act,  in  stenosis  of  the  larynx  and  trachea,  much  stronger 
than  in  capillary  bronchitis ;  therefore  the  drawing  in  of  the 
supra-clavicular  fossse  is  more  noticeable  in  the  former  case.  The 
younger  the  child  the  narrower  its  bronchi,  therefore  the  quicker 
there  may  be  manifested,  in  the  case  of  bronchitis,  appearances 
of  aspiration  on  the  chest  walls ;  in  children  under  one  year,  .i 
slight  depression  of  the  intercostal  spaces  may  be  noted  in  almost 
every  bronchitis. 

Ca]Mllary  Ijronchitis  belongs  to  the  most  dangerous  diseases- 
of  childhood,  being  usually  accompanied  l)y  (|uitc  high  and  con- 
tinuous fever,  often  leading  to  an  insufficient  oxidation  of  the 
blood,  which  is  shown  by  cyanosis  and  other  sym])toms  of  CO2 
poisoning.  Ca])illar\  l)rnnchitis  is  also  distinguished  by  occur- 
ring especially  in  small  children  under  two  }ears  of  age. 

Transition  from  bronchitis  to  pneumonia  is  a  gradual  one, 
making  itself  evident  b\-  the  a])pearance  of  crepitant  and  con- 
sonant rales,  but  later  on  ])y  bronchial  breathing  and  dullness. 

Some  similarity  to  capillary  bronchitis  is  represented  by 
BRONCHIAL  ASTHMA.  This  disease,  dependent  upon  spasm  of  the 
muscles  of  the  small  bronchi,  is  recognized  by  the  appearance  of 
periodically  repeated  attacks  of  violent  dyspnoea,  with  a  loud,  thin 
(high)  whistle  in  the  chest,  audil)le  even  at  some  distance  and 
accompanied  by  stasis  of  the  venous  bloo<l  and  cyanosis.  This, 
dyspnoea  resembles  that  occurring  in  capillary  bronchitis,  but 
with  the  difference  that  in  asthma  the  expiration  is  especiallv 
labored,  therefore  the  depression  of  the  yielding  portions  of  tlie 
chest  during  expiration  is  not  so  marked.  But  instead  of  that  on.^ 
may  notice  signs  of  distended  lungs  (sinking  of  the  diaphragm 
and  diminution  of  the  cariliac  dullness)  and  the  increased  activ- 
ity of  the  expiratory  muscles  (the  abdominal  w^alls  because  ot" 
tension  of  the  abdominal  muscles  during  expiration  appear  upon 
touch  very  hard,  tense).  The  attacks  end  with  the  appearance  of 
moist  rales  and  the  discharge  of  abundant  watery  sputum  in 
which  (even  in  children)  Charcot-Leyden  crystals  may  be  found. 
These  microscopical  crystals  may  be  of  great  value  for  the  diag- 
nosis in  doubtftd  cases. 

The  main  difference  as  to  capillary  bronchitis  consists  in  that 
asthtuatie  dyspiio'a  sets  in  quickly,  amidst  complete  health,  but  is- 


DISEASES    OF   RESPIRATORY    SVSTE.M  285 

of  short  duration — from  a  couple  of  minutes  uj)  to  a  few  hours — 
and  then  disappears  with  equal  rapidit\.  J""ever,  in  the  case  of 
asthma,  is  either  entirely  absent  or  the  temperature  rises  not 
higher  than  38  to  38.5  degrees  C.  ( 100.4  to  101.3  degrees  F.)  in 
the  axilla.  During  the  paroxysm  only  a  loud  whistle  is  to  be 
heard  on  auscultation  of  the  chest;  small  rales  which,  if  they 
appear  at  all,  are  noted  only  later  in  the  period  of  disappearance 
of  the  dyspnoea. 

It  is  much  more  difficult  to  recognize  asthma  when  the  same 
appears  as  a  complication  of  a  common  bronchitis.  In  such  cases 
the  disease  begins  with  coryza,  false  croup,  or  bronchitis,  but 
after  some  time  dyspncea  suddenly  sets  in,  with  whistling  rales 
and  cyanosis.  The  patient  remains  in  such  a  condition  either  a 
few  hours  or  from  three  up  to  five  days,  and  then  the  dyspnoea 
•becomes  milder,  and  only  an  ordinary  catarrh  of  the  middle  and 
large  bronchi  obtains.  The  rapidity  of  the  course  and  the  absence 
of  small  rales,  and  sometimes  of  fever,  excludes  in  similar  cases 
capillary  bronchitis.  Bronchitis  complicated  wdth  asthma  is  char- 
acterized : 

(i)  By  the  absence  of  correspondence  between  violent 
■dyspnoea  and  increased  activity  of  the  diaphragm,  on  the  one  part, 
and  by  the  insignificance  of  the  physical  symptoms  on  the  other. 

(2)  The  predominance  of  the  thin  whistle  over  the  rales. 

(3)  Quick  development  of  emphysema  (distension  of  the 
kings). 

(4)  Considerable  decrease  of  dyspnoea  during  sleep. 

As  special  individual  predisposition  is  necessar)'  for  the  de- 
velopment of  bronchial  asthma,  it  is  characteristic  that  a  child 
so  possessed  is  prone  to  asthmatic  attacks  as  soon  as  he  takes 
sick  with  bronchitis. 

In  diagnosing  asthma  it  is  also  always  desirable  to  clear  up 
its  3etiolog}^  In  children  one  occasionally  meets  with  the  essen- 
tial form  of  asthma  developing  without  any  noticeable  causes, 
occurring  even  in  children  of  the  earliest  age,  for  instance,  under 
one  vear.  In  the  aetiology  of  essential  asthma,  as  well  as  in  other 
neuroses,  hereditary  predisposition  to  nervous  diseases  plays  a 
significant  part.     I'rench  authors'^'  regard  asthma  as  a  manifesta- 


*Grancher:   Traiic  dcs  iiuiladii's  dc  rciifaiicc  I.   11.  page  J/. 


286  DISEASES    OF    RESPIRATORY    SYSTEM 

tion  of  the  arthritic  diathesis  and  place  this  malady  in  the  same- 
category  as  migraine,  obesity,  podagra,  renal  calculi  and  diabetes. 

Among  occasional  causes  of  asthma  in  children  predisposed 
to  it  is  exposure  to  cold  (snuffles,  bronchitis),  over-exertion 
(physical  as  well  as  mental),  foul  stomach,  etc.  In  other  cases 
again  there  is  observed  symptomatic  asthma  during  hyperplasia- 
of  the  bronchial  glands  (this  is  the  most  frequent  cause,  so  that 
among  the  causes  which  predispose  to  asthma  are  included  also 
rachitis  and  scrofula),  and  reflex  asthma  in  diseases  of  the  nose,, 
bronchi  and  in  hypertrophy  of  the  tonsils,  as  well  as  in  stomach 
diseases  (asthma  dispepticum,  of  Henoch). 

It  is  noteworthy  that  asthma  in  children,  whatever  its  cause- 
ma}-  be.  admits  of  a  better  prognosis  than  in  adults,  because  in 
the  majority  of  cases,  one  inay  say  almost  always,  it  disappears- 
with  age  (at  about  fourteen  or  fifteen  years). 

Regarding  chronic  bronchitis,  its  diagnosis  need  not  be  dis- 
cussed minutely.  Its  symptoms  are  the  same  as  in  acute  bron- 
chitis, from  which  it  differs  by  the  absence  of  fever  and  by  the 
protracted  course.  Chronic  bronchitis  in  children  seldom  lasts 
during  a  whole  year ;  in  summer  time  the  cough  usually  stops,, 
reappearing  in  the  fall  and  winter.  Chronic  bronchitis,  or  dis- 
position to  frequent  relapses  of  cough,  usually  develops  on  the- 
foundation  of  chronic  malnutrition,  whatever  this  may  be  due  to, 
scrofula,  rachitis,  or  anaemia,  and  especially  often  in  children  who 
suffer  with  adenoid  vegetations  in  the  naso-pharyngeal  cavity.  In 
the  treatment  of  infantile  chronic  cough  this  circumstance  must  be 
particularly  looked  for. 

Syniptomatic  bronchitis  necessarily  occurs  during  la  grippe, 
pertussis  and  measles  and  almost  always  in  typhoid  and  acute 
miliary  tuberculosis.  Here  we  shall  speak  only  of  the  first  two- 
morbid  forms  in  which  cough  appears  as  the  most  prominent 
symptom. 

We  define  two  forms  of  la  grippe:  (i)  endemic,  and  (2) 
epidemic  la  grippe  {influenza  endemica  and  epidemica).  The- 
former  occurs  annually  in  Moscow  during  the  cold  weather,  that 
is,  in  the  fall  and  winter,  while  the  latter  form  appears  as  epi- 
demics divided  by  intervals  of  several  years'  duration,  being  not 
much  dependent  upon  the  season  and  climate. 

The  second  setiological  difference  between  endemic  la  grippe- 


DISEASES   OF   RESPIRATORY    SYSTEM  287 

and  the  epidemic  consists  in  that  the  former  spreads  slowly,  in- 
creasino-  gradually  (the  first  cases  occur,  for  instance,  in  Sep- 
tember, an<l  tlie  highest  development  of  the  epidemic  coincides 
with  December  or  January),  while  the  latter  reaches  its  maximum 
in  the  given  locality  in  a  short  time  (two  or  three  weeks)  and 
with  equal  rapidity  disappears  to  affect  new  communities,  spread- 
ing over  the  earth  with  remarkable  speed. 

Epidemic  inlluenza  not  infrequently  assumes  the  character  of 
a  pandemic,  and  is  therefore  called  pandemic  la  grippe. 

The  third  aetiological  difference  consists  in  tliat  endemic  la 
grippe  chiefly  affects  children  (who  become  sick  not  only  oftener 
than  grown  persons,  but  also  more  severely),  but  during  epi- 
demic la  grippe  adults  suffer  oftener  and  with  more  severity.  On 
this  account  our  epidemic  la  grippe  might  be  called,  in  analogy 
with  cholera,  infantile  la  grippe. 

Regarding  the  symptoms,  catarrh  of  the  mucous  membrane 
of  the  respiratory  organs  is  the  chief  indication  of  infantile  la 
grippe  (therefore  it  is  also  called  endemic  bronchitis),  but  in  a 
true  la  grippe  there  is  general  weakness  and  other  symptoms  on 
the  part  of  the  nervous  system  in  the  form  of  manifold  painful 
sensations. 

The  common  name  for  both  these  forms,  "la  grippe,"  may  be 
explained  by  the  similarity  of  both  diseases  from  the  ^etiological 
as  well  as  clinical  point  of  view  : 

( 1 )  Both  belong  to  infectious,  contagious,  miasmatic  dis- 
eases (in  both  cases  people  are  attacked  in  whole  families,  infect- 
ing each  other). 

(2)  In  both  diseases  the  latent  period  is  short,  being  equal, 
approximately,  to  twenty-four  up  to  seventy-two  hours. 

(3)  Once  affected  with  this  or  that  form  of  la  grippe  does 
not  give  immunity  against  a  relapse. 

(4)  Catarrhs  of  the  mucous  membranes,  although  not  al- 
ways being  present  in  epidemic  la  grippe,  belong  in  the  majority 
of  cases  among  the  cardinal  or  chief  symptoms  during  some 
epidemics. 

(5)  The  duration  of  the  disease  is  short  in  uncomplicated 
cases  (three  to  seven  days). 

(6)  The  usual  termination  is  in  recovery. 


288  DISEASES    OF   RESPIRATORY    SYSTEM 

(7)  The  most  frequent  complications  are,  in  both  cases, 
pneumonia,  usually  of  irregular  course,  and  inflammation  of  the 
middle  ear. 

We  shall  first  describe  endemic  la  grippe  (synonyms — epi- 
demic bronchitis,  infantile  la  grippe),  and  then  epidemic  la 
grippe  (true  or  pandemic  la  grippe,  influenza). 

Under  the  name  of  infantile  la  grippe  we  understand  an  epi- 
demic infectious  catarrh,  affecting  several  mucous  membranes  at 
once,  or  in  succession,  and  in  such  instances  it  begins  with  the 
nose,  from  thence  rapidly  spreading  over  neighboring  parts  (con- 
junctivae, fauces)  and  down  over  the  bronchi  and  sometimes 
also  to  the  intestines. 

Age  exhibits  a  noticeable  influence  upon  the  readiness  of 
vulnerability  to  this  disease,  as  children  from  one-half  to  five 
years  of  age  mostly  become  affected.  Age  influences  not  only  the 
frequency  of  occurrence  of  the  disease,  but  also  its  intensity ; 
the  younger  the  child  the  more  severe,  generally  speaking,  the 
illness.  After  the  age  of  seven,  abortive  and  mild  cases  of  influ- 
enza occur  much  oftener  than  the  well  developed  forms,  but  the 
infectiousness  of  both  is  equal,  and  in  diagnosing  influenza  in 
a  child  who  had  not  been  out  of  doors  and  thus  had  no  reason 
for  catching  cold,  one  should  beai'  in  mind  that  the  source  of  a 
family  epidemic  of  influenza  is  frequently  acute  rhinitis  in  an 
adult  member  of  the  family. 

The  beginning  of  tlie  disease  is  usually  preceded  by  the 
prodromal  period  in  the  form  of  an  afebrile  coryza  and  slight 
cough  lasting  a  few  days.  The  disease  itself  begins  with  fever, 
temperature  rising  quickly,  often  reaching  40  to  40.5  degrees  C. 
(104  to  104.9  degrees  F.)  during  the  first  evening. 

Simultaneously  with  fever  there  also  appear  catarrhal  symp- 
toms (if  they  already  exist,  then  they  increase),  first  in  the  form 
of  snuffles  and  conjunctivitis,  and  later  on  cough. 

The  course  of  fever  during  la  grippe  is  ver}'  erratic ;  in  sonie 
cases  we  have  febris  continua  remittens  with  considerable  morn- 
ing remissions  and  evening  elevations,  as  in  typhoid  (39  to  39.5 
degrees  C. — 102.2  to  103. i  degrees  F.  in  the  morning  and  39.5 
to  40.5  degrees  C.  or  103. i  to  104.9  degrees  F.  in  the  evening). 
Such  a  high  and  continuous  fever  is  observed  especially  in  small 
children   under   two  years,  denoting  a  verv  acute  course   of  la 


DISHASKS    OF    RKSl'lRAI'ORV    SVSTKM  289 

grippe  which  ends,  in  such  cases,  by  a  more  or  less  sharp  crisis  in 
from  eight  to  fifteen  days.  Catarrh  spreads  rapidly  from  the 
nose  to  the  bronchi,  and  not  uncommonly  also  to  the  lungs,  that 
is,  pneumonia  sets  in.  Such  an  influenza  is  often  mistaken  for 
typhoid  or  pneumonia  crouposa. 

In  other  cases  the  fever  shows  rapid  variations  during  the 
day;  either  it  falls  to  the  normal  or  rises  again  to  about  40  de- 
grees C.  (104  degrees  F.).  One  cannot  determine  any  regularity 
in  these  changes  of  the  temperature,  nevertheless  under  a  strained 
interpretation  the  disease  may  be  taken  for  febris  intermittens. 

The  second  constant  symptom  of  la  grippe  is  catarrh  of  the 
mucous  membranes.  As  a  rule,  first  of  all,  the  nose  and  the  con- 
junctivae become  affected,  then  one  or  two  days  later,  but  some- 
times simultaneously,  the  throat  and  the  larynx.  Increased  flow 
of  tears,  with  reddening  of  the  eyelids,  impermeability  of  the  nose 
and  secretion  from  the  latter  of  transparent  fluid,  sometimes  a 
harsh  voice,  and  more  rarely  symptoms  of  laryngeal  stenosis  with 
a  dry  ringing  cough  (false  croup),  characterise  this  period. 

Nasal  catarrh  is  of  itself  an  important  symptom  in  the  diag- 
nosis of  influenza,  but  its  meaning  is  still  greater  if  at  the  same 
time  shooting  pains  in  the  ear  are  complained  of.  This  symp- 
tom is  especially  important,  because  it  develops  early,  usually  the 
first  or  second  night.  High  as  the  temperature  may  be,  or  how- 
ever severe  the  symptoms  on  the  part  of  the  nervous  system  in 
the  form  of  delirium,  restlessness,  etc.,  yet  if  on  the  second  day 
of  the  disease  nasal  catarrh  or  shooting  pain  in  the  ear  are  pres- 
ent, influenza  may  be  diagnosticated,  because  such  a  symptom - 
complex  as  violent  fever,  rhinitis  and  shooti)ig  pain  in  the  ear  in 
the  bcgin)iing  of  the  disease  is  pathognomonic  of  la  grippe.  It 
is  self-evident  that  absence  of  earache  by  no  means  excludes  la 
grippe. 

After  about  three  days,  or  later  on,  resolution  of  the  catarrh 
begins ;  muco-purulent  fluid  discharges  from  the  nose,  harsh  voice 
and  ringing  cough  disappear,  the  fever  stops  and  the  patient  re- 
covers in  seven  to  ten  days,  provided  the  catarrh  docs  not  spread 
further.  Such  slight  cases  in  which  the  catarrh  does  not  extend 
below  the  trachea  are  especially  peculiar  to  older  children.  The 
lightest  cases  of  la  grippe,  which  manifest  themselves  only  by 
coryza  and  reddening  of  the  conjunctivi-e.  may  be  over  in  two  (■'• 
four  days.    This  is  an  abortive  form  of  the  disease. 


290  DISEASES    OF   RESIM  R AT' )KV    SYSTEM 

In  the  great  majority  of  cases  the  catarrh  is  not  Hmited  to  the 
nose,  but  spreads  further  and,  often  avoiding-  the  larynx,  directly 
affects  the  bronchi.  Such  an  occurrence  is  usually  marked  by  an 
acceleration    of  the  fever. 

Bronchitis  during  la  grippe,  in  distinction  from  common 
catarrh  of  the  bronchi,  is  exhibited,  first,  by  a  very  severe  and  fre- 
quent dr\  cough,  the  physical  signs  on  the  part  of  the  bronchi  be- 
ing insignificant ;  and,  second,  by  the  fact  that  this  catarrh  does 
not  become  quickly  resolved.  In  this  regard  la  grippe  is  similar  to 
pertussis,  as  in  both  cases  the  j)arents  claim  that  the  child  has 
a  fit  of  coughing  so  violent  that  the  face  sometimes  becomes 
red  from  the  elTort.  and  the  paroxysm  terminates  with  vomiting, 
while  one  can  find  alnmst  nothing  in  the  chest  to  explain  such  a 
cough.  Besides  the  absence  of  the  whistling  inspiration,  which 
is  so  characteristic  of  the  pertussis  cough,  the  further  difiference 
is  that  in  la  grijipe  a  more  or  less  high  fever  is  present,  which  i:> 
not  characteristic  of  whooping-cough  ;  and  that  in  the  former  dis- 
ease the  coughing  fits  are  especially  violent  in  the  mornings  and 
evenings,  while  in  whooping-cough  the  attacks  are  more  pro- 
nounced at  night. 

In  the  case  of  a  new  exacerbation  of  fever  the  catarrh  may 
spread  to  the  small  bronchi,  alveoli  (pneumonia),  and  sometimes 
to  the  bowels. 

Besides  these  cardinal  symptoms  of  fever  and  catarrh,  the 
nervous  system  always  becomes  affected  during  any  distinctly 
developed  influenza.  The  most  constant  symptoms  besides  head- 
ache, which  never  is  absent,  are  insomnia,  sometimes  very  persist- 
ent in  the  night-time,  and  irritability  in  the  daytime.  The  patient 
gives  the  impression  of  a  very  disagreeable  child.  This  excessive 
capriciousness  or  wrath  is  highly  characteristic  of  la  grippe,  espe- 
ciall\-  when  we  have  to  consider  the  differential  diagnosis  between 
influenza  and  typhoid ;  the  typhoid  patients  are  quiet. 

In  graver  cases  of  la  grippe  the  children  are  delirious,  fre- 
quently from  the  very  first  night  (an  essential  dift'erence  from 
typhoid,  in  which  the  delirium  usually  appears  at  end  of  the  first 
week)  ;  or  they  jump  up  in  the  night,  cry  as  if  frightened  by 
something,  and,  perhaps,  even  do  not  recognize  the  members  of 
the  family. 

The  course  of  la  grippe  is  an  extremely  in;lefinite  and  irregu- 


DISEASES   OF   RESl'lRATi  )KV    S>STEM  29I 

lar  one,  therefore  the  prognosis  regardiiii^-  its  duration  cannot 
be  very  exact,  l)ut  it  is  favorable  quo  ad  vitani,  as  la  grippe  usually 
ends  with  recovery,  even  when  complicated  with  pneumonia. 

Severe  cases  of  la  grippe  may  be  protracted  for  several 
weeks,  such  a  chronic  course  predisposing  to  the  development  of 
chronic  pneumonia  and  tuberculosis. 

Regarding  the  diagnosis  of  la  grippe  the  disease  is  most 
often  confused  with  aciite  bronchitis,  from  which  it  dififers : 

First,  by  its  epidemic  occurrences  and  contagiousness. 

Second,  by  the  fact  that  besides  the  bronchi  other  mucous 
membranes  also  become  involved. 

Third,  the  degree  of  the  fever,  its  duration,  and  the  violence 
or  the  frequency  of  the  cough  usually  do  not  correspond  to  the 
symptoms  of  the  catarrh. 

Fourth,  the  catarrhs  during  la  grippe  become  protracted, 
notwithstanding  the  patient  is  kept  in  bed ;  and  finally. 

Fifth,  during  la  grippe  the  nervous  system  also  becomes 
involved. 

About  the  resemblance  between  la  grippe  and  the  first  period 
of  whooping-cough  the  reader  is  referred  to  the  section  devoted 
to  the  latter.  Here  we  shall  only  note  that  the  higher  the  tem- 
perature in  the  beginning  of  the  disease,  the  more  probable  is  it 
la  grippe,  and  vice  versa,  if,  despite  the  normal  or  subnormal  tem- 
perature, the  resolution  of  the  catarrh  of  the  nose  and  tracliea 
is  delayed,  the  patient  meanwhile  being  kept  in  bed,  then  whoop- 
ing-cough is  probable. 

During  the  first  twenty-four  or  seventy-two  hours  the  diag- 
nosis may  vary  between  la  grippe  and  the  prodromal  period  of 
vicasles.  The  character  of  the  redness  of  the  mucous  membrane 
of  the  throat,  conjunctivse  and  mouth  decides  the  point  in  the 
best  wa\'.  In  measles  the  rechicss  of  these  mucous  membranes, 
especially  of  the  soft  and  hard  palates,  is  usually  a  spotted  one, 
in  la  grippe,  however,  as  in  common  catarrhs,  it  is  dift"use. 

Second,  the  character  of  the  epidemic  is  here  very  important. 
It  is  obvious  that  if  in  any  given  family  wherein  someone  already 
has  measles,  a  child  takes  ill  with  nasal  catarrh  and  epiphora 
(increased  flow  of  tears),  then  we  should  rather  suspect  measles, 
and  not  la  grippe,  even  if  no  spotted  redness  is  present  in  the 
throat,  which  is  far  from  being  constant  in  measles. 


292  DISEASES   OF   RESPIRATORY    SYSTEM 

Finally  the  third,  although  the  less  important,  sign  we  have 
is  sneezing,  which  occurs  much  oftener  in  the  prodromal  period 
of  measles  than  in  influenza.  This  depends,  perhaps,  upon  photo- 
phobia also  being  more  intense,  and  it  is  known  that  under  the 
influence  of  bright  light  sneezing  appears  even  in  healthy  per- 
sons having  no  rhinitis. 

In  its  further  course  la  grippe,  accompanied  with  constant 
fever,  and,  perhaps,  with  diarrhoea,  simulates  typhoid. 

The  diagnosis  is  based  upon  the  absence  of  symptoms  which 
especially  point  toward  typhoid,  as  rose  spots  and  spleen  tumor, 
and  the  simultaneous  presence  of  symptoms  which  are  not  pecul- 
iar to  typhoid  altogether,  but  are  characteristic  of  la  grippe,  as 
nasal  catarrh  and  irritability.  A  recent  swelling  of  the  spleen  is 
against  la  grippe. 

If  rhinitis  has  disappeared,  then  the  history  gives  very  essen- 
tial data;  the  disease  began  with  rhinitis,  fever,  the  cough  was 
from  the  very  first  the  chief  symptom,  the  fever  was  regular, 
would  often  fall  to  the  normal  level — la  grippe ;  but  if  the  disease 
began  gradually  with  headache,  loss  of  appetite,  and  fever  in  the 
evenings ;  if  at  the  beginning  there  was  neither  rhinitis  nor 
cough ;  and  the  latter  made  itself  evident  toward  the  end  of  the 
week,  the  fever  increasing  gradually  and  had  reached  its  max- 
imum on  the  fourth  or  the  fifth  day,  remaining  on  the  same  level, 
with  morning  remissions — then  typhoid. 

The  age  is  also  of  important  diagnostic  value ;  under  two 
years  typhoid  seldom  appears,  while  la  grippe  very  often. 

The  difference  between  these  two  diseases  is  a  sharp  one,  not- 
withstanding which  fact  errors  in  diagnosis  occur  very  often. 
The  physician  either  mistakes  la  grippe  for  typhoid,  or  he  cannot 
altogether  place  his  case  in  any  definite  category  of  diseases. 
All  such  difficulties  arise  only  from  the  fact  that  the  physician 
does  not  well  bear  in  mind  the  distinctive  points  of  la  grippe. 

Regarding  the  symptoms  and  course  of  epidemic  la  grippe 
such  a  manifoldness  exists  that  different  forms  of  this  disease 
are  usually  recognized,  dependent  upon  whether  one  or  another 
set  of  symptoms  are  predominant,  as,  for  instance,  influenza 
cephalica  ( soinnolence,  violent  delirium,  miconsciousness),  influ- 
enza abdominalis,  s.  gastrica  (loss  of  appetite,  vomiting,  ab- 
dominal pain,  diarrhcea),  influenza  neuralgica   (pains  along  the 


DISEASES   OF   RESPIRATORY    SYSTEM  293 

peripheral  nerves  as  well  as  in  the  hack  and  extremities j,  influ- 
enza thoracica,  s.  catarrhalis  (catarrhs  and  inflammations  of 
respiratory  org'ans). 

As  common  symptoms  of  all  these  forms  there  appear,  be- 
sides the  rapid  and  vast  spread  of  the  epidemic  when  people  of 
all  ages  fall  sick,  the  sudden  onset  of  the  disease,  in  the  form  of 
quick  elevation  of  the  temperature,  as  well  as  its  short  duration, 
accompanied  with  severe  headache  and  considerable  general  weak- 
ness ;  uncomplicated  cases  usually  end  with  a  profuse  perspiration 
in  from  two  to  five  days. 

It  has  been  previously  mentioned  that  in  adults  true  influenza 
is  more  severe  than  in  childhood.  At  least  during  the  epidemic 
of  1889  and  1890  this  difference  was  so  evident  that  I  find  it  more 
convenient  to  describe  the  course  of  la  grippe  in  adults  and  chil- 
dren separately. 

In  grozvn  persons  the  chief  symptoms  are  nervousness,  that 
is,  painful  symptoms,  while  catarrhs  of  the  respiratory  organs 
(which  usually  are  essential  symptoms  of  influenza)  are  either 
absent  altogether,  or  appear  late,  for  instance,  at  the  end  of  fever. 
The  disease  almost  always  begins  suddenly  (seldom  after  malaise 
of  one  or  two  days'  duration)  with  severe  fever  (39  to  39.5  de- 
grees C. — 102.2  to  103. 1  degrees  F.)  during  the  first  evening, 
simultaneously  with  which  severe  pains  appear;  headache,  pain 
in  the  eyes,  which  increases  upon  movement  of  the  eyeballs,  pain 
in  the  back  and  legs,  especially  in  the  calves.  Comparatively  in- 
frequent are  pains  in  other  parts  of  the  body,  for  instance,  in  the 
form  of  general  hypergesthesia  of  the  skin  and  intercostal  neural- 
gise,  migraine,  as  well  as  arthralgise. 

Among  the  constant  symptoms  there  are  also  loss  of  appe- 
tite, great  weakness,  dizziness  when  the  patient  attempts  to  stand 
up,  sleeplessness,  more  rarely  delirium  or  sopor.  All  mentioned 
pains  are  characterized  by  their  sudden  onset  or  rapidity  of  devel- 
opment, and  by  not  having  been  accompanied  by  any  symptoms 
of  inflammation  (in  painful  places  redness  is  absent,  also  swelling, 
as  well  as  elevation  of  temperature)  and,  finally,  by  their  being  of 
short  duration,  rapidly  disappearing  soon  after  the  fever  ceases, 
and,  only  in  exceptions,  neuralgia  sometimes  remains  for  a  greater 
or  less  period  of  time.    On  the  contrary,  loss  of  appetite  and  gen- 


294  DISEASES   OF   RESPIRATORY    SYSTEM 

eral  weakness  are  persistent  in  almost  all  patients  during  two  or 
three  weeks,  which  does  not  correspond  at  all  to  the  brevity,  nor 
to  the  severity,  of  the  fever. 

During  the  last  epidemic  of  la  grippe  all  evidences  were,  in 
many  cases,  limited  to  these  nervous  symptoms  alone  and  also  to 
the  fever,  catarrhs  being,  at  the  same  time,  absent.  In  other 
cases  again  catarrhs,  and  mostly  those  of  the  respiratory  organs, 
occurred,  namely,  coryza,  redness  of  the  fauces,  hoarseness  and 
cough ;  more  seldom  gastric  haemorrhages  were  met  with,  as, 
also,  were  vomiting  and  diarrhoea.  In  the  majority  of  patients  the 
cough  appeared  late,  that  is,  only  after  the  disappearance  of  the 
pains  and  fever. 

All  these  symptoms  apparently  had  a  nervous  connection,  as, 
for  instance,  coryza  was  accompanied  by  severe  pain  in  the  fore- 
head, over  the  glabella ;  laryngo-tracheitis,  by  spasmodic  dry 
cough,  sometimes  with  vomiting,  as  in  whooping-cough;  tracheo- 
bronchitis, by  severe  pain  along  the  sternum  and  dyspnoea.  In 
case  of  vomiting,  the  patients  complained  of  pain  in  the  epigas- 
trium ;  and  in  diarrhoea  of  abdominal  pain. 

()f  symptoms  which,  although  occurring  in  the  minority  of 
cases,  yet,  to  some  extent,  make  the  diagnosis  difficult  and  lead 
to  confusion  of  influenza  with  dengue,  may  be  mentioned  pains 
in  the  joints,  especially  in  the  knees  (without  inflammatory  ap- 
pearances) ;  and  different  rashes,  either  in  the  form  of  urticaria, 
or  those  resembling  measles  or  scarlet  fever. 

The  duration  of  influenza  in  grown  persons  is,  in  mild  cases 
from  one  to  two  days,  in  the  moderate  or  severe  forms,  from  three 
up  to  five  and  even  ten  days.  At  any  event  the  duration  of  in- 
fluenza varies  greatly  as,  for  instance,  in  individual  cases  the 
febrile  condition  in  a  non-complicated  influenza  not  infrequently 
lasts  about  three  or  four  weeks  and  longer ;  however,  in  cases 
of  chnviic  influenza,  a  moderate  febrile  condition  without  any 
local  appearances,  even  without  snuffles  and  cough,  may  sometimes 
continue  up  to  three  months,  terminating  with  complete  recovery. 
Such  chronic  cases  not  very  rarely  occurred  among  children  dur- 
ing the  winter  1897  and  1898.  Complicating  pneumonia  was  usu- 
ally met  with. 

Regarding  the  symptoms  of  influenza  in  childhood,  it  is  cer- 
tain that  (luring  the  epidemic  of  i88q  children  were  not  so  severely 


DISKASKS    OI'    Ri:Sl'IU.\  IllKN'    SVSTi:.\I  295 

sick  as  adults.  /;;  child roi  not  0)i!y  zi'crc  catarrhs  z'ery  often  ab- 
sent, but  also  pains  in  the  back  and  cak'cs.  Very  often  children 
from  eight  up  to  ten  years  of  age  did  not  complain  of  such  pains 
even  when  asked  about  the  same,  so  that  the  whole  disease  was 
manifested  in  children  b\  the  sudden  onset  of  fever  (39  to  40  de- 
grees C.  or  102.2  to  104  degrees  ¥.),  headache  and  general  weak- 
ness. After  two  or  three  days  all  symptoms  would  disappear,  and 
the  diagnosis  of  induenza  could  be  established  only  on  the  ground 
of  the  character  of  the  epidemic,  that  is,  that  all  members  of  the 
family,  without  exception,  became  sick  in  a  very  short  time. 

In  childhood,  comparatively  oftener  than  in  adults,  there 
would  appear,  in  the  beginning  of  the  disease,  nausea  and  repeated 
vomiting,  as  well  as  epistaxis.  The  comparative  moderation  of  the 
disease  in  children  was  also  manifested  by  the  quick  recover}-, 
(that  is,  the  appetite  and  the  strength  returning  earlier),  and  by 
the  fact  that  complications  rarely  developed,  especially  pneumonia. 
Different  rashes  sometimes  occurreil  in  children,  but  they  did  not 
differ  in  anything  from  rashes  of  adults.  The  liver  and  the 
spleen,  in  influenza  of  children,  did  not  l)ecome  noticeably 
enlarged. 

As  influenza  is  distinguished  by  much  greater  variety  of 
symptoms  than  our  endemic  la  grippe,  therefore,  in  the  diiferen- 
tial  diagnosis  of  the  former  very  many  diseases  should  be  touched 
upon  with  reference  to  this  or  that  symptom.  So,  for  example,  a 
severe  headache  may  cause  suspicion  of  meningitis,  especially 
in  conjunction  with  an  incipient  vomiting  :  pain  in  the  legs,  espe- 
cially in  the  joints,  leads  one  to  think  of  rheumatism ;  repeated 
vomiting  and  fever,  of  stomach  catarrh  ;  pain  in  the  back  with 
high  fever  and  vomiting — small  pox  ;  catarrh  of  the  nose,  eyes  and 
larynx — measles  ;  diffuse  erythemata — scarlet  fever. 

The  diagnosis,  in  all  cases,  may  be  aided  b\'  the  character  of 
the  epidemic,  that  is.  by  the  epidemic  occurrence  of  different 
forms  of  influenza  in  adults  and  children,  and  by  the  symptoms  of 
the  latter  not  being  persistent.  The  doubts  of  the  physician  can- 
not last  longer  than  two  or  three  days,  because,  after  such  time. 
the  symptoms  of  la  grippe  begin  to  abate. 

In  sporadic  cases,  or  in  the  l)eginn-ing  of  an  epidemic,  the 
diagnosis  niay  be  established  only  in  typically  developed  cases 
and,  especially,  from  the  presence  of  symptoms  on  the  part  of  the 


296  DISEASES   OF   RESPIRATORY    SYSTEM 

nervous  system  in  the  form  of  collapse  which  does  not  correspond 
either  to  the  severity,  or  to  the  duration,  of  the  febrile  condition ; 
also  from  various  kinds  of  pain,  which  have  been  mentioned. 

Sporadic  cases  of  infantile  influenza,  characterized  by  the  ab- 
sence of  specific  pains,  and  not  rarely  also  of  catarrhs,  are  not 
easy  to  be  diagnosticated  precisely,  and,  in  the  absence  of  an  epi- 
demic, such  cases  are  reported  by  physicians  as  febris  gastrica, 
or  f.  herpetica,  f.  rheumatica  or  ephemera. 

The  influenza  of  1889,  because  of  the  frequent  absence  of 
catarrh,  was  very  similar  to  dengue,  for  which  it  was  mistaken 
by  some  French  physicians.  Both  these  diseases  affect  a  great 
number  of  inhabitants ;  both  belong  to  the  class  of  miasmatic- 


Fig.   3c — Influenza-bacilli    (Lcnharlz). 

contagious  diseases ;  both  come  on  suddenly  amidst  complete 
health,  starting  with  rapid  elevation  of  temperature  and  headache, 
backache  and  pain  in  the  limbs :  both  end  by  crisis  after  two  or 
three,  or  in  five  to  seven  days ;  in  both  diseases  relapses  are  ob- 
served one  to  three  days  after  the  end  of  the  first  attack ;  finally, 
in  both  diseases  manifold  rashes  appear  on  the  skin,  in  the  form 
of  spotted  or  diffuse  erythemata  or  urticaria.  The  resemblance 
increases  still  further  in  that,  in  dengue,  there  sometimes  appear 
catarrhs  of  the  mucous  membranes  of  the  nose,  mouth,  and  throat, 
or  dyspnoea  without  catarrh  of  the  bronchi.  On  the  part  of  the 
digestive  organs,  in  both  cases  are  observed,  as  constant  symp- 
toms, loss  of  appetite,  coated  tongue  and  inclination  to  constipa- 


DISEASES    OF   RESIMRATOKV    SYSTEM  297 

tion,  and  sometimes  vomiting-;  furlhermore,  peculiar  to  both  dis- 
eases, are  sleeplessness,  headache,  nose-bleed,  collapse  and  slow 
recovery.     The  prognosis  is  favorable  in  both  affections. 

The  dift'erences  are  that  the  pains  are  localized,  in  dengue, 
not  so  much  in  the  calves  as  in  the  joints,  the  latter  becoming 
swollen  as  in  acute  rheumatism ;  but  in  influenza  this  never  hap- 
pens. Relapses  in  dengue  are  common,  as  in  relapsing  fever,  like- 
wise the  cutaneous  rash  is  rarely  absent ;  while  in  influenza  both 
occur  in  the  minority  of  cases.  The  main  difference  is  that,  in 
dengue,  catarrhs  of  the  respiratory  organs  are  always  absent. 
Thus,  the  similarity  between  influenza  and  dengue  may,  in  separ- 
ate cases,  be  complete,  they  may  be  almost  identical ;  but  a  great 
difference  will  be  found  in  the  general  character  of  the  epidemic ; 
influenza  belongs  to  catarrhal  diseases,  dengue  does  not. 

In  all  doubtful  cases  of  influenza  occurring  with  coryza  or 
cough,  the  diagnosis  may  be  effected  through  the  bacterioscopic 
examination  of  the  sputum,  or  of  the  nasal  mucus,  for  Pfeiffer's 
bacilli.     (Fig.  30.) 

The  influenza  bacillus  is  peculiar  first  of  all  by  being  very 
small,  the  length  is  only  twice  or  three  times  its  breadth,  the 
ends  rounded ;  they  have  no  capsule ;  in  the  pendulous  drop  they 
are  immobile ;  they  stain  slowly,  therefore  the  glass  covered  with 
smeared  sputum  must  be  left  in  the  stain  not  less  than  ten  min- 
utes ;  for  staining,  Loftler's  methylene-blue  or  an  aqueous  solu- 
tion of  fuchsine  are  the  best ;  they  do  not  stain  by  the  method  of 
Gram.  Obtaining  pure  cultures  is  possible  only  in  the  pres- 
ence of  haemoglobin  or  leucocytes.  Pfeift'er  recommends  for  this 
purpose  agar  covered  with  blood.  The  tube  containing  the  cul- 
ture is  placed  for  twenty-four  hours  in  an  incubator  at  the  tem- 
perature of  37  to  42  degrees  C.  (98.5  to  107.6  degrees  F.).  The 
colonies  of  the  influenza  bacillus  are  very  characteristic,  and  can- 
not be  confounded  with  anything  else  (they  appear  as  very  small, 
colorless,  as  if  watery,  drops  which  seldom  reach  the  size  of  a 
pinhead  ;  usually  they  are  so  small  that  they  are  distinctly  seen 
only  through  a  magnifying  glass, 

The  diagnostic  value  of  bacilli  is  lessened  by  the  fact  that 
first,  they  are  met  with  only  in  the  sputum  and  nasal  mucus,  but 
not  in  the  blood,  so  that  the  bacterioscopic  examination  is  not  ap- 
plicable to  the  nervous  and  gastric  forms  of  influenza;  and  sec- 


298  DISEASES   OF   RESPIRATORY    SYSTEM 

ond,  in  broncho-pneumonije  not  due  to  influenza  Pfeiffer  found 
pseudo-influenza  bacilli,  which  are  very  similar  to  true  bacilli  in 
their  form,  their  relation  to  stains  and  their  ability  to  give  cul- 
tures only  in  the  blood-agar ;  but  are  distinguished  by  being  in 
cultures  of  greater  size,  and  with  a  tendency  to  form  long  threads. 

The  differential  diagnosis  of  epidemic  la  grippe  from  the 
infantile  form  is  difficult  only  in  catarrhal  varieties  of  the  former, 
because  the  symptoms  are  identical  in  both  morbid  states  and  the 
exact  diagnosis  impossible  on  the  ground  of  the  bacterioscopic 
examination  (the  microbes  of  infantile  la  grippe  are  yet  un- 
known). 

From  typhoid  fever  the  catarrhal  form  of  influenza  easily 
differs  by  the  nasal  catarrh,  which  occurs  in  typhoid  only  as  an 
exception ;  serious  difficulties  are  encountered  in  the  diagnosis 
by  cases  of  protracted  influenza  without  coryza.  In  favor  of 
influenza,  there  arc  to  be  noted  in  the  beginning  the  rapid  eleva- 
tion of  temperature  during  the  first  day  of  the  disease,  with 
pains  in  the  limbs  (in  children  the  last  symptom  seldom  occurs)  ; 
and,  during  the  second  week,  absence  of  typhoid  rose-spots)  ; 
Widal's  test  and  spleen  tumor  (swelling  of  the  spleen  sometimes 
occurs  in  influenza,  therefore  its  presence  does  not  exclude  this 
disease),  and  a  considerably  ((uickcned  pulse  (in  typhoid  fever  m 
children  older  than  five  years  the  pulse  is  relatively  retarded). 

Whooping-cough,  like  la  grippe,  also  belongs  to  general  in- 
fectious, epidemic  and  contagious  diseases.  This  malady  is  char- 
acterized by  a  peculiar,  convulsive  cough,  because  of  the  localiza- 
tion of  the  disease  in  the  mucous  membrane  of  the  upper  respira- 
tory passages,  and,  perhaps,  also  in  the  medulla  oblongata. 

In  the  course  of  whooping-cough  there  are  to  be  distin- 
guished : 

( 1 )  The  prodromal  or  catarrhal  period. 

(2)  The  period  of  spasmodic  cough,  and 

(3)  The  period  of  resolution,  or  the  blenorrhoeic  period. 
The  first  period,  the  catarrhal,  begins  either  in  the  form  of 

mild  la  grippe,  or  as  a  marked  pharyngitis.  In  the  former  case 
the  patient's  temperature  increases  (38  to  38.5  degrees  C. — 100.4 
to  101.3  degrees  F.)  and  simultaneously  he  begins  to  cough,  the 
results  of  physical  examination  of  the  chest  being  negative  (phar- 
yngitis,   s.    laryngo-tracheitis),    sometimes    coryza    also   appears. 


DISEASES    OI'-   RESPIRATORV    SYSTEM  299 

The  picture  of  the  cHseasc  is  so  siinihir  to  pharyngitis  or,  when 
■coryza  is  present,  to  a  shght  la  grippe,  that  the  diagnosis  during 
the  first  three  days  may  be  made  perhaps  only  on  the  ground  of 
the  urinary  examination  {vide  infra)  and  the  character  of  the 
•epidemic. 

In  the  further  course  whooping-cough  may  be  suspected  be- 
cause slight  la  grippe  usually  does  not  become  protracted,  but,"  on 
the  contrary,  the  resolution  of  the  catarrh  begins  after  about 
•three  days  from  the  commencement  of  the  disease,  the  fever  stops, 
the  cough  becomes  less  frequent  and  softer,  while  in  whooping- 
cough  it  is  the  contrary ;  even  if  the  fever  disappears,  nevertheless 
the  cough  remains  dry  and  frequent,  especially  during  the  ftrst 
hours  of  the  night  (this  is  characteristic  of  whooping-cough), 
W'hile  Dover's  powder  given  in  the  evening  usually  does  not  re- 
lieve the  cough.  During  the  second  week  the  diagnosis  of  whoop- 
ing-cough, in  the  majority  of  cases,  may  be  made  with  great  prob- 
ability on  the  ground  that,  at  the  same  hours  of  the  night,-  the 
•cough  assumes  a  paroxysmal-like  character.  Before  it  consisted 
■of  separate  coughing  spells,  but  now  of  several  coughing  attacks, 
and  the  greater  their  number  the  more  they  are  characteristic  of 
whooping-cough  (follow  each  other  so  rapidly  that  the  child  can 
effect  an  inspiration  only  after  a  whole  series  of  coughing  at- 
tacks). Such  a  cough  resembles  that  of  the  second  (convulsive) 
period,  differing  from  the  same  by  the  absence  of  vomiting  at  the 
end  of  the  paroxysm  and  of  spasm  of  the  glottis,  upon  which  de- 
pends the  whistling  inspiration  so  characteristic  of  the  real  whoop- 
ing-cough. 

The  transformation  of  the  catarrhal  period  into  the  spas- 
modic one  is  thus  occasioned  gradually ;  a  peculiar  convulsive 
-cough  first  appears  once  or  twice  during  the  night,  and  then  also 
during  the  daytime.  This  cough  is  so  characteristic  that  if  heard 
•once  it  will  never  be  forgotten,  and  whooping-cough  ma\-  thus  be 
recognized  from  an  adjacent  room. 

The  cough  in  pertussis  consists  in  the  following :  the  patient 
begins  to  cough  at  once  violently;  his  face  grows  cyanotic,  the 
paroxysmal  fits  of  coughing  follow  each  other  uninterruptedh' 
until  there  is  but  little  air  suppl}-  in  the  lungs  ;  then  the  patient 
takes  a  deep  inspiration,  but  at  the  same  time  the  glottis  co!i- 
tracts  spasmodically,  and  the  air,  while  passing  the  narrow  open- 


300  DISEASES   OF   RESPIKATORV    SYSTEM 

ing',  produces  a  loud  sound,  which  resembles  a  whistle,  audible 
throug"h  several  rooms.  Immediately  after  that  the  cough  begins 
again,  followed  by  a  renewed  whistling  sound,  etc.,  thus  occur- 
ring from  two  to  five  times  and  even  more,  until  the  paroxysm 
terminates  with  vomiting,  or  the  elimination  of  a  great  quantity 
of  viscid  mucus  or  saliva,  accompanied  by  nausea. 

'  The  whooping-cough  jiaroxysms  are  most  often  repeated  at 
night. 

Violent  j^aroxysms  of  whooping-cough  are  very  disagreeable 
to  the  child,  therefore  it  often  happens  that  the  patient,  feeling 
the  attack  coming  on,  becomes  excited,  his  face  expressing  anx- 
iety. This  is  very  characteristic  of  pertussis,  and  nothing  similar 
occurs  in  bronchitis. 

In  estimating  the  intensity  of  the  disease  attention  should  be 
given  to  the  violence  of  paroxysms  and  their  frequency.  If  the 
number  of  paroxysms  does  not  exceed  fifteen  during  twenty-four 
hours,  then  the  whooping-cough  may  be  regarded  as  a  mild  one ;. 
if  from  fifteen  to  twenty-four  times,  moderate ;  and  if  more  than 
twent\-four  times,  then  a  severe  attack.  As  to  the  severity  of  the 
attacks  one  may  jutlge,  first,  by  the  number  of  the  whistling  in- 
spirations from  the  beginning  to  the  end  of  the  particular  attacks 
of  coughing.  In  severe  cases  vomiting  comes  on  only  after  the 
fourth  or  the  sixth  whistling  inspiration,  hut  in  tlie  mild  ones, 
after  the  first. 

The  stenotic  whistle  during  cough  api)cars  as  a  more  con- 
stant symptom  of  whooping-cough  than  vomiting,  because  in 
ordinary  cases  it  is  evident  at  any  paroxysm,  while  vomiting  takes 
place  about  twice  or  thrice  a  day,  especially  after  those  attacks 
of  coughing  which  come  on  immediately  after  eating.  Therefore,, 
from  the  frequency  of  vomiting  one  may  judge  about  the  severity 
of  the  whooping-cough. 

Regarding  the  diagnosis,  it  is  important  to  notice  that  the 
paroxysm  of  whooping-cough  may  be,  in  the  majority  of  cases, 
produced  by  different  means  calculated  to  impel  the  child  to- 
cough.  Older  children  may  be  plainly  told  to  cough  pur- 
posely, but  in  smaller  ones  coughing  is  excited  by  pressing  with 
the  finger  over  the  jugular  fossa  or  larynx,  and  still  better  wdien 
examining  the  throat  by  using  a  tongue  depressor.     It  is  also 


DISEASES    OF   RESPIRATORY    SYSTEM  '  30 1 

known  that  ])aroxysms  may  take  place  upon  excitement  of  the 
chikl   (huit;liing,  crying,  etc.). 

Of  other  symptoms  of  whooping-cough,  which  permit  the 
physician  to  diagnosticate  the  same  witliout  hearing  the  cough, 
the  habitus  of  the  patient,  ulceration  of  the  frenuhwi  of  the  tongue, 
and  the  characteristic  peculiarities  of  the  urine  are  important. 

Because  of  often-repeated  obstructions  to  the  circulation  of 
the  blood  during  the  cough  there  arise  puffiness  of  the  face,  swell- 
ing of  the  eyelids,  reddening  of  the  conjunctivae,  sometimes  bloody 
extravasations  in  the  sclerje  and  capillary  haemorrhages  in  the  skin 
of  the  face  and  most  often  in  the  eyelids. 

Ulceration  of  the  frenulum  of  the  tongue  occurs  only  in  chil- 
dren having  incisors,  and  the  sharper  they  are  the  quicker  an  ex- 
coriation develops.  Therefore  it  appears  much  oftener  in  children 
under  two  years  than  after  five  years  of  age.  The  diagnostic 
meaning  of  the  ulcers  of  the  frenulum  is  great,  as  it  occurs  almost 
exclusively  in  whooping-cough. 

To  the  peculiar  properties  of  the  urine  in  whooping-cough 
attention  was  directed  by  Blumenthal  and  Hippius,  of  Moscow. 
They  noticed  that  the  urine  of  whooping-cough  patients,  notwith- 
standing its  pale  color,  was  of  high  specific  gravity  (from  1022 
up  to  1035  according  to  Vogel's  urometer,  instead  of  the  normal 
loio  to  1012),  and  rich  with  uric  acid,  which  being  very  easily 
soluble  becomes  deposited  in  the  form  of  minute  whitish  powder, 
which,  as  the  microscopical  examination  shows,  is  uric  acid. 

I  verified  Blumenthal-Hippius'  conclusions  in  more  than  ten 
cases  of  whooping-cough  and  did  not  see  even  one  exception  to 
the  rule  established  by  them,  and  therefore  hold  it  entirely  justi- 
fied to  call  such  a  urine  "whooping-cough  urine."  In  the  diag- 
nosis of  whooping-cough  it  is  especially  important  that  the  pecul- 
iarities of  the  urine,  according  to  Blumenthal  and  Hippius,  appear 
very  early,  namely,  even  during  the  period  of  incubation  of  the  dis- 
ease, before  the  appearance  of  any  cough,  or  in  the  very  beginning 
of  the  catarrhal  period,  when  the  diagnosis  of  the  pertussis  can- 
not be  based  on  anything  else. 

Further  observations  will  have  to  show  whether  such  a  urine 
does  not  also  occur  during  other  kinds  of  cough,  for  instance, 
in  an  afebrile  pharyngitis  or  in  a  mild  influenza. 

The  diagnosis  of  pertussis  cannot  rest  alone  upon  the  whist- 


302  DISEASES   OF   RESPIRATORY    SYSTEM 

ling  siridor  accompanying  the  cough,  because  such  whistHng  in- 
spiration may  be  absent.  It  may  also  disappear  in  patients  in. 
whom  it  had  been  present ;  very  often,  for  instance,  it  is  absent 
during  whooping-cough  in  nurslings  ;  it  may  disappear,  in  patients 
in  whom  it  had  been  observed,  because  of  the  development  of 
weakness,  or  as  the  result  of  some  complication ;  and,  finally,  it 
may  be  absent  in  mild  and  abortive  cases  of  whooping-cough  in 
which  the  disease  does  not  go  further  than  the  catarrhal  period, 
with  some  indications  of  a  spasmodic  nature.  Sometimes  the  diag- 
nosis of  such  cases  is  possible  only  in  connection  with  the  occur- 
rence of  other  instances,  or  an  epidemic. 

In  a  common,  uncomplicated  whooping-cough,  auscultation 
and  percussion  of  the  chest  give  negative  results,  as  the  catarrh 
does  not  go  beyond  the  trachea  and  the  first  bronchi. 

Regarding  fever,  it  may  l>e  said  that  the  temperature  is 
normal  during  the  period  of  complete  development  of  the  disease 
and,  according  to  all  authors,  the  presence  of  elevated  temperature 
during  the  spasmodic  period  denotes  some  complication.  How- 
ever, one  cannot  agree  altogether  with  this  last  opinion,  as  cases 
of  whooping-cough  are  met  with  in  which  fever,  starting  in  the 
catarrhal  stage,  lasts  through  the  whole  spasmodic  period,  and  no- 
complication  occurs,  so  that,  in  diagnosing  complications  of 
whooping-cough,  one  should  bear  in  mind  that  a  febrile  condition 
does  not,  per  se,  prove  the  development  of  a  complication. 

After  the  three  or  four  weeks'  existence  of  the  spasmodic 
period  there  is  a  gradual  transition  into  the  third  stage,  that  of 
resolution  or  blenorrhoea.  The  cough  becomes  less  frequent  and 
weaker ;  the  vomiting  and  whistle  disappear ;  diffuse,  moist,  large 
and  medium  rales  are  heard  in  the  chest ;  the  sputum,  formerly 
light  and  viscid,  becomes  yellowish  and  may  easily  be  expector- 
ated. After  about  two  or  three  weeks  the  cough  ceases  altogether 
and  the  patient  recovers. 

It  is  remarkable  that  in  a  patient  recovering  from  whooping- 
cough  there  remains  for  a  long  time  (for  a  few  months)  a  pre- 
disposition to  modified  attacks  of  the  disease,  in  that  as  soon  as 
he  catches  cold  or  falls  ill  with  la  grippe,  leading  to  involvement 
of  the  upper  air  passages,  then  the  cough  immediately  assumes  a 
spasmodic  character,,  that  is,  the  patient  coughs  until  the  face 
becomes  reddened  and  the  whistling  inspiration  arises  because  of 


i)isi-:.\s]-:s  ()]•'  Ki:si'iR A  TORY  s^■s'n■:.M  303 

spasm  of  the  glottis.  This  is  a  relapse  not  of  the  specific  whoop- 
ing-cough, hut  only  ot  a  pertussis-like  cough  which  does  not  in- 
fect anyhody  and,  if  the  ])atient  remains  within  doors,  passes  over 
as  quickly  as  a  conmion  hronchitis. 

In  view  of  the  symptoms  described,  and  the  course,  the  diag- 
nosis of  whooping-cough  is  easy,  as  the  cough  in  this  disease  is 
so  characteristic  that  it  is  quite  impossible  not  to  recognize  it,  U 
only  it  has  been  once  heard.  If  such  a  cough  occurs  in  several 
children  of  a  given  family,  then  the  diagnosis  cannot  be  doubtful. 

Some  similarity  to  whooping-cough  may  be  presented  by  cases 
of  laryngo-pharyngitis  when  the  patient  begins  to  cough  dryly 
and  continues  until  vomiting  results,  but  at  the  same  time  the 
characteristic  whistling  inspiration  is  absent,  and  the  vomiting 
also  does  not  last  long,  if  the  patient  remains  within  his  room. 

A  pertussis-like  cough  also  occurs  in  some  cases  of  hyper- 
plasia and  caseous  degeneration  of  the  bronchial  glands.  Besides 
the  fact  that  the  resemblance  between  these  two  coughs  is  quite 
a  remote  one,  the  essential  difference  consists  in  the  course  and 
the  history.  Whooping-cough  is  characterized  by  beginning  with 
a  dry,  short  cough  which  after  a  few  days  becomes  spasmodic, 
wdiich  in  its  turn  after  two  or  four  weeks  begins  to  decrease,  be- 
coming moist  and  catarrhal.  In  hyperplasia  of  the  glands  the 
cough  first  occurs  as  a  chronic  bronchitis  which,  long  after,  may 
resemble  a  whooping-cough,  (the  child  coughs  until  reddening 
of  the  face ;  the  cough  is  sometimes  accompanied  by  a  whistling 
inspiration)  remaining  in  this  stage  of  development  an  indefinite 
time.  Such  children  are  usually  rachitic  or  scrofulous  and  suiter 
with  swelling  of  the  neck  glands,  exhibiting  either  symptoms  of 
stenosis  of  the  trachea  (due  to  compression),  or  other  symptoms 
of  compression  by  the  bronchial  glands  (page  275).  Here  it  must 
be  added  that  although  enlargement  of  the  bronchial  glands  very 
often  occurs  in  childhood,  nevertheless  the  pertussis-like  cough 
seldom  appears  in  the  absence  of  whooping-cough  itself. 

It  has  been  mentioned  that  one  must  not  confound  pertussis 
with  the  spasmodic  cough  (accompanied  by  whistling  and  vomit- 
ing) which  develops  after  exposure  to  cold  in  those  convalescent 
from  whooping-cough. 

The  diagnosis  of  whooping-cough  is  not  difficult  even  in  am- 
bulatory cases.     The  diagnosis  in  such  is  based : 


304  DISEASES   OF   RESPIRATORY    SYSTEM 

(i)  On  the  disease  being  of  epidemic  character  (several 
members  of  the  family  cough). 

(2)  The  paroxysm  of  cough  is  accompanied  by  whistling 
inspiration  and  reddening  (cyanosis)  of  the  face,  ending  with 
vomiting  and  expectoration  of  sputum,  even  in  small  children 
(children  under  five  years  sufifering  with  an  ordinary  bronchitis 
never  expectorate  the  sputum,  but  swallow  it)  ;  therefore,  if  the 
mother  states  that  the  child,  after  the  attack  of  coughing,  dis- 
charges the  sputum,  then  this  circumstance  (due  to  vomiting)  is 
very  characteristic  of  whooping-cough. 

(3)  The  cough  is  more  severe  at  night  than  in  the  daytime. 

(4)  Puffiness  of  the  face  and  swelling  of  the  eyelids. 

(5)  Erosions  of  the  frenulum  of  the  tongue. 

(6)  In  many  cases  the  negative  results  of  the  physical  ex- 
amination of  the  chest,  nothwithstanding  the  mother's  claim  that 
the  child  coughs  very  severely,  are  also  characteristic. 

It  is  far  more  difficult  to  recognize  whooping-cough  in  the 
first  part  of  the  catarrhal  period.  About  the  signs  by  which  one 
may  guided  at  this  time  we  have  already  spoken ;  the  most  es- 
sential are  the  whooping-cough  urine  and  the  existence  of  a  prob- 
able epidemic  in  the  same  family  or  neighborhood. 

[Some  authors,  as  Meunier,  Wanstall,  claim  that  in  the 
catarrhal  stage  of  whooping-cough  there  is  an  inverse  ratio  be- 
tween the  polynuclear  leucocytes  and  the  lymphocytes ;  or  that 
the  latter  are  sometimes  equal  in  number  to  the  polynuclear  neu- 
trophile  cells ;  therefore  this  sign  may  be  of  value  for  the  diag- 
nosis of  whooping-cough  in  its  early  stage. — Earle.] 

In  diagnosticating  whooping-cough  in  nurslings,  one  should 
bear  in  mind  that  at  this  age  the  disease  may  occur  without  a 
whistling  sound,  but  it  is  important  to  know  that  the  majority 
of  coughing  fits  end  with  vomiting;  that  the  fits  of  coughing  fol- 
low each  other  uninterruptedly,  producing  reddening  of  the  face ; 
that  an  ulcer  often  arises  under  the  tongue ;  and  that  a  violent 
cough  obtains  without  fever  and  often  even  without  any  rales. 

Because  of  the  absence  of  the  inspiratory  whistle  the  physician 
often  does  not  recognize  whooping-cough  in  nurslmgs,  mistaking 
the  same  for  a  "teetlting  cough,''  but,  of  course,  without  reason, 
because  a  cough  during  dentition  dift'ers  in  no  manner  from  a 
bronchitis  cough  ;  it  soon  passes  away  and  is  not  prone  to  be  com- 
plicated with  vomiting. 


DISEASES   OF   RESPIRATORY    SYSTEM  305 

Amoiii;"  pulmonary  diseases  occurring  witliout  dullness  of  the 
percussion  note,  but  \vith  coughing  (because  of  the  accompan\- 
ing  bronchitis)  and  dyspnoea,  we  have  piihnonary  a^dcnia  a)id  oii- 
f'hyscnia. 

QKdema  of  the  lungs,  in  its  physical  features,  resembles 
diffuse  bronchitis,  as  it  is  manifested  by  dyspnoea  while  the  per- 
cussion note  is  clear,  and  in  lx)th  lungs  numerous  moist,  small 
and  large  rales  are  present. 

The  diagnosis  of  pulmonary  oedema  ma}'  be  considerably 
assisted  by  the  accompanying  symptoms  which  clear  up  its  aeti- 
ology. Here  are  referred,  for  instance,  general  dropsy  because  of 
nephritis  or  heart-lesion,  heart-failure  during  severe  infectious 
diseases,  retarded  blood  circulation  in  the  lungs  in  the  presence  of 
an  abundant  pleuritic  exudation,  pneumonia,  etc. 

Grave  cases  are  characterized  by  the  rapid  development  of 
dyspnoea  together  with  cyanosis,  coolness  of  the  extremities  and 
somnolence  due  to  CO..  poisoning. 

Capillar}'  bronchitis  never  extends  so  rapidly  over  both  lungs, 
but  increases  gradually,  beginning  with  the  posterior  and  in- 
ferior portions. 

But  the  most  characteristic  symptom  of  pulmonary  oedem:. 
is  undoubtedly  the  expectoration  of  an  abundant,  very  fluid, 
foam}',  yellowish  or  slightly  blood}'  sputum. 

In  the  majority  of  text-books  on  children's  diseases  emphy- 
sema is  not  discussed  in  a  separate  chapter  because  a  real  emphy- 
sema characterized  by  dilatation  of  pulmonary  alveoli  with  sub- 
sequent atrophy  of  the  interalveolar  walls  and  capillaries  almost 
never  occurs  in  childhood.  What  is  called,  in  children,  "emph}- 
sema"  is  indeed  not  emphysema,  but  dilatation  of  the  lungs — 
dilatatio  puhnonnni — wdiich  is  a  temporary  condition.  Such  a 
dilatation  of  the  lungs  very  often  occurs  in  whooping-cough,  as 
well  as  in  chronic  bronchitis,  and  is  especially  noted  by  the  dis- 
placement of  the  boundaries  of  the  clear  pulmonary  sound  in  the 
area  of  the  anterior  margins  of  the  lungs  (decrease  of  the  cardiac 
dullness)  and  in  that  of  the  lower  margins  (lowering  of  the 
upper  boundary  of  the  hepatic  dullness  down  to  the  seventh  and 
even  the  eighth  rib).  It  seldom  occurs  that  the  chest  assumes, 
because  of  increase  of  its  horizontal  dimensions,  a  "bariel- 
shaped"  form,  as  is  commonly  observed  in  adults.    In  very  chronic 


306  DISEASES    OF    KESPIRATORV    SYSTEM 

cases  other  symptoms  of  a  real  emphysema  may  also  appear,  as 
for  instance,  symptoms  on  the  part  of  the  circulatory  organs  in 
the  form  of  contraction  of  the  arteries,  and  stasis  in  the  pulmon- 
ary circulation  and  in  the  veins  of  the  whole  body ;  the  accentu- 
ated second  pulmonic  sound  and  pulsation  in  the  epigastrium 
denotes,  in  such  cases,  dilatation  and  hypertrophy  of  the  right 
ventricle  and  increased  pressure  in  the  pulmonary  artery  (stasis 
in  the  veins  of  the  pulmonary  circulation)  ;  and  enlargement  of 
the  liver,  obstructive  urine  and  (cdema  ()f  the  feet  indicate  stasis 
in  the  veins  of  the  greater  circle. 

DISEASES  OF  THE  LL'XcJS  CHARACTERIZED  BY  THE 
APPEARANCE  OF  A  DCLL  PERCUSSION  SOUND. 

Croupous  Pneumonia.  Pneumonia  crouposa  occurs  in  chil- 
dren of  any  age,  not  excluding  even  nurslings,  not  less  often  than 
in  adults.  It  always  has  a  very  acute  course,  being  marked  by 
the  sudden  onset  of  violent  fever  and  the  rapid  development  of 
hepatization  of  a  whole,  or  almost  a  whole,  lobe  of  the  lungs. 
According  to  the  place  of  formation  of  the  exudate  a  dull  note 
is  obtained,  and  as  the  hepatized  lung  conducts  the  sound  l>etter 
than  an  inflated  one,  then  over  the  place  of  dullness  l)ronchial 
respiration  and  bronchophony  are  heard,  and  upon  palpation  there 
is  increased  vocal  fremitus. 

These  general  symptoms  occur  in  ty])ical  as  well  as  in  anom- 
alous forms  of  croupous  pneumonia,  variations  being  indicated  by 
the  different  character  of  concomitant  s}'mptoms  and  by  the 
■course. 

Typical  croupous  pneumonia  begins  in  children  older  than 
seven  years,  as  w^ell  as  in  adults,  with  chills ;  in  those  younger 
with  some  approximation  to  such  an  initiation  (coolness  of  the 
•extremities,  cyanosis  of  the  lips),  sometimes  with  general  convul- 
sions, oftener  with  vomiting,  but  for  all  cases  the  rapid  onset 
of  violent  fever  is  characteristic  :  even  during  the  first  twenty-four 
hours  the  temperature  reaches  about  40  degrees  C.  (104  degrees 
F.)  and  more.  Simultaneously  there  appears  a  short,  dry,  pain- 
fnl  cough  and  a  hurried  respiration  (in  children  vuider  two  years 
about  eighty  per  minute,  in  older  ones  about  forty  to  fifty,  with 
dilatation  of  the  nostrils).  Children  older  than  five  or  six  years 
from  the  very  first  days  complain  of  pain  in  the  side,  increasing 


DISEASES    OF    KESI'IKA  roKV    SVSTIl.M  307 

during-  cough  and  dcc'i)  ins])iration.  which  cousidcrahly  assists  the 
diagnosis  in  the  heginning  of  the  disease  when  symptoms  of 
hepatization  of  the  huigs  have  not  yet  appeared. 

Children  from  three  up  to  five  years  of  age  ahnost  never 
complain  of  pain  in  the  side  of  the  chest,  l)ut  they  point  with  the 
same  constancy  to  abdominal  pain  either  in  the  epigastrium  or 
lower,  but  in  general  without  an  exact  localization.  The  alxlom- 
inal  pain  is,  in  the  beginning  of  pneumonia,  in  small  children,  of 
quite  marked  diagnostic  importance,  as  infants  usually  do  not 
complain  of  abdominal  pain  when  they  become  affected  with  acute 
gastrites,  w^hich  may  resemble  croupous  pneumonia  in  point  of 
the  incipient  vomiting.  Peritonitis,  however,  cannot  even  l)e 
thought  of  here,  as  the  pain  in  the  abdomen  during  pneumonia 
usually  does  not  increase  upon  pressure,  therefore  its  location 
cannot  be  determined  by  palpation.  This  pain  is  only  a  seeming 
one,  reflected,  that  is,  it  is  wrongly  localized  by  the  child. 
[Reg'arding  abdominal  pain  in  pneumonia  of  children  men- 
tion occurs  in  a  note  on  p.  217.— Earle.]  Thus,  if  we  find  a  patient 
wdth  violent  fever,  quickened  respiration,  wath  dilatation  of  the 
nostrils,  and  short,  dry,  frequent  cough,  and  we  suspect  from 
such  evidences  a  beginning  pneumonia,  then  the  abdominal 
pain,  even  accompanied  by  repeated  vomiting,  coated  tongue,  etc., 
not  only  does  not  contraindicate  this  proposition,  but  indeed  con- 
firms it.  The  pain,  in  our  opinion,  has  greater  significance  than 
even  the  quickened  respiration  which  occurs  during  any  high 
fever;  so  that  one  should  remember  that  frequent  respiration 
may  only  have  significance  as  a  symptom  of  hmg-  afiFection  when 
accompanied  by  dilatation  of  the  nostrils  and  cough,  and  when 
its  frequency  is  increased  disproportionally  to  the  pulse.  Normal- 
ly, to  one  respiration  there  correspond  three  or  four  pulse-beats, 
and  in  acute  diseases  of  the  lungs  the  ratio  changes  as  i  :  1^/2  or 
2.  If  pain  on  breathing  increases  considerably,  then  w'e  have 
sighing  expiration  in  which  each  expiration  terminates  with  a 
short  sighing  efl:'ort.  It  should  be  borne  in  mind  that  such  sigh- 
ing character  of  the  respiration  also  occurs  in  dyspncea  from  other 
causes. 

[Pfaundler  records  from  his  seven  years'  observations  that 
in  children  sufifering  with  pneumonia,  especially  the  cerebral 
form,  the  knee-jerk  is  entirely  absent  or  diminished  on  one  or 


3o8  DISEASES   OF   RESPIRATORY    SYSTEM 

both  sides,  while  in  healthy  children  this  occurs  very  seldom. 
Pfaundler  could  detect  this  sign  even  before  the  general  physical 
signs  made  themselves  evident.* — Earle.] 

Judged  by  the  symptoms  just  mentioned  a  beginning  pneu- 
monia may  be  suspected  with  great  probability.  A  more  definite 
conclusion  cannot  be  made  even  by  means  of  the  results  of  phys- 
ical examination  of  the  chest,  as  hepatization  does  not  occur  early. 
It,  therefore,  often  requires  two  or  three  days  to  reach  a  positive 
diagnosis. 

[Weill  called  attention  to  one  sign  which  appears  very  early 
during  croupous  pneumonia  in  children,  and  which  is  always  pres- 
ent. This  is  lack  of  expansion  of  the  subclavicular  region  of  the 
affected  side,  even  when  the  pneumonic  process  involves  the  base 
of  the  lung.  It  is  observed  sometimes  in  the  very  beginning  of 
the  disease  and  is  persistent  during  the  whole  course  of  the 
process.**  Weill's  observations  have  been  confirmed  by 
Gillet.*** — Earle.  ] 

At  first  percussion  gives  either  negative  results,  or  a  tym- 
panitic tone  is  obtained  over  the  point  of  the  inflammation,  but 
this  note  does  not  decide  the  question.  On  auscultation  one  may 
hear  crepitant  rales,  in  adults,  over  a  limited  area,  but  these  are 
almost  always  absent  in  children  during  the  first  period  of  pneu- 
monia, because  to  make  them  evident,  the  child  would  have  to 
take  deep  inspirations,  whereas  his  breathing,  because  of  pain, 
is  very  shallow. 

Earlier  than  other  signs  of  hepatization  of  the  lungs  bron- 
chophony appears,  which  renders  it  possible  to  foretell  in  what 
part  hepatization  will  develop  after  about  two  days. 

In  the  further  course  of  pneumonia  the  fever  remains  for 
several  days  at  the  same  level  or  rises  still  higher,  up  to  41  or  42 
degrees  C.  (105.8  to  107.6  degrees  F.),  and  remains  in  the  form 
of  febris  continua  with  insignificant  variations  during  from  five 
to  nine  days,  when  it  terminates  by  crisis  in  a  few  hours,  the 
temperature  falling  below  the  normal,  usually  accompanied  by 
abundant  perspiration. 

During  this  time  the  local  evidences  on  the  part  of  the  lungs 

*Munch.  Med.  Woch.,  July  22,  1902. 

**Quote(l  from  Am.  Jouru.  of  Med.  Sci.,  Apri',  1902. 

**''Gazette  des  Hopitau.v,  1903,  p.  749. 


DISKASES    OF    KICSl'I  K AK  IKN     SVS'H'.M  3O9 

become  clearly  appreciable;  corresponding  lo  this  or  thai  loi)e 
of  tlie  lungs  there  is  considerable  iliilliiess,  loud  bronchial  respira- 
tion,  bronchopJiony  and  increase  of  the  vocal  fremitus. 

With  the  fall  of  temperature  the  period  of  resolution  of  the 
inflammation  sets  in  ;  in  place  of  dry  bronchial  respiration  crep- 
itation appears,  the  dull  note  and  other  signs  of  hepatization  of 
the  lungs  gradually  decline,  and  in  a  few  (la}'s  the  normal  stan- 
dard is  reached. 

A  due  consideration  of  the  s}nii)toms  named  renders  the 
diagnosis  easy  during  the  active  phase  of  development  of 
the  disease.  If  the  dull  sound  corresponds  to  the  inferior  lobe  of 
the  lung  the  cjuestion  may  then  arise  regarding  a  pleuritic  exu- 
date. Although  moderate  exudation  gives  a  dull  percussion  note, 
yet,  as  the  lungs  are  not  completely  compressed,  and  between  tlie 
observer's  ear  and  the  bronchi  there  is  located  air-containing  pul- 
monary tissue,  therefore  not  a  bronchial  respiration  is  heard  upon 
auscultation,  but  only  a  weakened  vesicular  one;  bronchophony 
is  also  absent,  and  the  vocal  fremitus  is  necessarily  weakened. 

The  occurrence  of  vesicles  of  herpes  on  the  lips  or  within 
the  nose  is  also  strongly  presumptive  of  pneumonia  and  against 
pleurisy,  because  it  occurs  very  often  during  pneumonia,  and  al- 
most never  in  pleurisy. 

Nevertheless,  cases  are  observed  in  which  the  diiTcrentiation 
between  pneumonia  and  pleurisy  is  not  so  simple  as  it  seems  to 
be ;  it  is  the  more  difficult  the  less  is  the  amount  of  exudate  and 
the  younger  the  child.  The  greater  difficulty  of  diagnosticating 
pleurisy  in  children  in  comparison  with  adults  depends  upon  the 
following  conditions  : 

(1)  There  is  no  sputum  (in  adults  a  bloody,  viscid,  extens- 
ible sputum  is  pathognomonic  of  pneumonia). 

(2)  It  is  difficult  to  examine  for  the  vocal  fremitus.  Gen- 
erally speaking  this  symptom  belongs  among  the  most  certain 
for  the  differentiation  of  pneumonia  from  pleurisy  ;  in  the  former 
it  is  increased;  in  the  latter,  decreased,  which  is  especiall\'  notice- 
able in  adults,  when  the  voice  is  low  ;  in  children,  however,  the 
voice  is  loud  and  this  makes  the  fremitus  pectoralis  less  distin- 
guishable. In  acute  pneumonia,  as  well  as  in  pleurisw  the  condi- 
tions are  still  more  unfavorable,  as,  on  account  of  pain,  children 
avoid  loud  talking  and  likewise  loud  crying ;  they  only  sigh  loudly 


3IO  DISEASES   OF   RESPIRATORY    SYSTEM 

or  groan  slio^htly,  which  is  insufficient  for  vocal  fremitus.  Further- 
more, if  pneumonia  is  accompanied  by  bronchitis  and  the  afferent 
bronchus  is  blocked  up,  then  the  vocal  fremitus  may  be  weak- 
ened, notwithstanding'  the  hepatization  of  the  lung,  and  simul- 
taneously the  bronchial  respiration  and  bronchophony  decrease 
also.  The  same  happens  in  the  so-called  massive  pneumonia 
(Grancher),  characterized  by  abundant  formation  of  exudate 
with  obstruction  of  bronchi  with  fibrinous  clots. 

(3)  Bronchial  respiration  in  pneumonia  may  be  weak,  or 
inaudible  altogether,  even  without  obstruction  of  the  bronchi, 
simply  because  the  child  breathes  feebly ;  and  on  the  other  hand 
such  a  respiration  also  frequently  occurs  in  pleurisy,  together 
with  bronchophony  (but  without  exaggeration  of  vocal  fremitus), 
and  in  cases  of  more  considerable  exudation  which  compresses 
the  pulmonary  tissue  completely,  leaving,  however,  the  bronchi 
open  to  the  passage  of  the  air. 

l^he  differential  diagnosis  of  doubtful  cases  of  pneumoni  i 
from  i^leurisy  is  based:  (a)  on  the  character  of  the  fever; 
(b)  on  the  form  of  the  dull  note,  and  (  c  )  on  the  course. 

(a)  There  are  few  diseases  which  are  accompanied  with 
so  high  a  tem]X"rature  as  croupous  pneumonia,  in  which  41  de- 
grees C.  (  105. cS  degrees  F.)  in  the  axilla  is  a  common  finding, 
even  42  degrees  C.  (107.6  degrees  F.)  exhibits  nothing  peculiar, 
such  a  temperature  being  neither  rare  nor  dangerous  ;  and  a  tem- 
perature below  40  degrees  C.  (  104  degrees  I"". )  during  the  whole 
first  week  of  the  disease  almost  excludes  pneumonia  (crouposa). 
In  pleurisy  it  is  dift'erent ;  the  beginning  of  the  disease  is  not  so 
sharp,  because  the  initial  elevation  of  temperature  does  not  occur 
so  rapidly  ;  during  the  first  week  there  is  seldom  more  than  40 
degrees  C.  (104  degrees  F.),  and  even  then  not  all  the  time,  as 
toward  morning  there  is  usually  a  marked  fall  (0.5  to  1.5  de- 
grees) ;  crisis  is  seldom  observed,  but,  on  the  contrary,  during 
the  second  or  third  week  the  morning  temperature  begins  to  show 
considerable  decrease,  ])erhaps  even  complete  intermissions  and 
thus  ends  with  lysis  in  flight  cases  in  alx>ut  three  weeks,  in  grave 
ones  much  longer.  Thus,  if  the  patient  coughs,  complains  of  pain 
in  the  side,  the  percussion  gives  a  dullness  in  the  posterior  part  of 
the  chest  from  the  half  of  the  scapula  downwards,  the  respiration 
being  at  this  point  indefinite,  or  weakly  bronchial,  the   fremitus 


DISEASES    dl"    KESl'lUAKiRN     SNSIE.M  31f 

impossible  tt>  be  (letennined,  tben,  in  main-  cases,  tbe  question 
nuist  be  decided  by  the  course  nf  teiii])erature  :  it  the  patient  had 
a  constant  fever  for  several  days  with  a  temperature  of  ahon; 
41  degrees  C.  (T05.8  degrees  V.),  then  it  is  most  probable  that  he 
has  pneumonia;  if,  however,  the  temperature  had  never  ascended 
to  40  degrees  C".  (104.  degrees  l'\ ) ,  tlvn  more  likel\'  pleurisy 
obtains. 

If  the  tem])erature  during  the  tirst  week  was  about  41  de- 
grees C.  (105.8  degrees  ¥.)  and.  nevertheless,  pleurisy  was  iouu  1 
as  the  cause  of  it.  then  one  may  fear  that  a  purulent  exudation 
has  taken  ])laee.  In  other  cases  such  temperatures  may  accom- 
pany exudative  i)leurisies  which  com])licale  ])neumonia.  and  a 
complication  of  that  kind  may  Ije  recognized,  if  the  relativelv  dull 
sound  peculiar  to  pneumonia  becomes  absolutely  dull,  if  the  vocal 
fremitus  (lisa])pears.  the  resistance  considerably  increases,  and  the 
intercostal  s]:>aces  become  protruded.  Bronchial  respiration  and 
bronchophony  not  infrequently  increase  considerably.  Since  the 
hepatized  lung  cannot  be  compressed  and  does  not  give  place  to 
the  exudate,  symptoms  of  displacement  of  neigh.boring  organs 
set  in. 

(b)  The  dull  sound  in  pneumonia  crotiposa,  in  its  area, 
corresponds  to  the  affected  lobe,  in  the  case  in  question  to  the  in- 
ferior lobe  of  the  lungs,  although  it  very  rarely  happens  that  the 
infiltration  occupies  the  whole  lobe,  the  anterior  margins  usually 
remain  free,  and  the  dull  sound  abruptly  ends  on  the  posterior 
axillary  line  or  somewhat  forwards  thereof,  but  does  not  involve 
the  anterior  surface  of  the  chest,  so  that  on  the  right  side,  for  in- 
stance, between  the  nipple  and  the  upper  boundary  of  the  liver. 
the  note  remains  clear.  It  is  also  characteristic  that  the  dull  sound 
in  pneumonia  ai)pears  almost  at  once  over  the  whole  surface. 
In  pk'uris}-  the  dull  sound  first  of  all  api)ears  in  the  lowest  portion 
of  the  chest  behind  and  then  slowly,  for  several  da}s,  rises  up- 
wards, and  when  the  half  of  the  scapula  is  reached,  then  it  ex- 
tends also  to  the  anterior  surface  of  the  chest  where  its  upper 
boundary  is  always  higher  than  on  the  back.  Such  a  definition  of 
the  dull  sound  is  very  characteristic  of  pleuritic  exudation  and 
serves  as  a  certain  criterium  for  its  distinction,  not  only  from 
pneumonia.  Init  also  from  hydro-thorax,  in  which  the  upper  boun- 
darv   of   the   dull   sotmd,   because  of  the   free   movement  of  the 


312 


DISEASES    OF   RESPIRATORY    SYSTEM 


fluid  in  the  pleural  cavity,  lies  on  the  horizontal  level,  when  the 
patient  is  in  a  sitting  posture,  that  is,  the  fluid  is  then  on  the  same 
level  behind  as  in  front  of  the  chest. 

Finally,  it  is  also  noteworthy  that,  during  a  considerable 
left-sided  exudation,  there  decreases  or  entirely  disappears  the  so- 
called  Traube's  semilunar  space,  which  does  not  diminish  during 
pneumonia  (  semilunar  space  of  Traube  is  the  region  of  the  tym- 
panitic smmd  of  the  stomach  extending  over  the  left  hypochon- 


Fig.   31 — Stniilunar   space   of    Traube    (after    Sahli). 

drium  ;  the  inferior  boundary  of  the  semilunar  space  is  formed 
by  the  lower  margin  of  the  left  half  of  the  chest,  and  the  upper 
by  a  curved  line  with  the  convexity  upwards,  which  reaches  the 
sixth  rib ;  the  lateral  boundaries  of  Traube's  space  are  limited 
by  the  mammillary  and  anterior  axillary  lines).     (Fig,  31.) 

In  case  of  large  pleuritic  exudations  it  is  not  easy  to  con- 
found pleurisy  with  pneumonia.  In  children  one  can  observe, 
earlier  than  in  adults,  the  dilatation  of  the  aflrected  half  of  the 


DISEASES    OF    KES1'1KA1'()K\'    SYSTEM  3I3 

chest,  noticeal:)lc  to  the  eve  and  which  may  be  easily  tleterniinecl 
by  measuring-  (the  difference  in  smah  children  is  1^2  to  2  centi- 
meters, in  older  ones  3  to  4  centimeters)  ;  also  the  diminution  of 
its  movability  during  respiration  and  the  displacement  of  the 
heart  or  the  liver.  Those  beginning  practice  should  bear  in  mind 
that,  even  in  the  presence  of  very  abundant  exudates  which  fill 
the  entire  half  of  the  chest  up  to  the  clavicle,  bronchial  respira- 
tion nevertheless  may  be  heard,  and  really  is  frequently  heard. 
If  bronchial  respiration  be  present,  tlien  there  is  also  broncho- 
phony, but  vocal  fremitus  will  be  in  any  case  weakened. 

If  the  dull  sound  occupies  the  whole  half  of  the  chest,  from 
the  clavicle  downward  and  from  the  vertebral  column  to  the 
sternum,  then  it  is  almost  certainly  a  pleurisy,  as  in  the  so-called 
total  pneumonia  (pneumonia  totalis)  the  anterior  borders  usually 
remain  free,  and  thus  along  the  sternum  the  note  will  be  clear 
W'ith  a  tympanitic  timbre.  On  the  contrary,  if  the  dull  sound 
•corresponds  to  the  upper  lobe  alone,  then  it  directly  points  toward 
pneumonia,  and  excludes  pleurisy. 

(c)  The  course  of  pneumonia  is  a  very  acute  one,  the 
febrile  period  ending  in  from  five  to  seven,  sometimes  in  eleven, 
■days,  and  a  few  days  later  the  physical  signs  of  hepatization  also 
•disappear ;  on  the  contrary,  pleurisy  is  usually  of  a  slow  course, 
the  fever  disappears  earlier  than  three  weeks,  and  the  dull  sound 
is  maintained  still  longer. 

(d)  If  despite  the  above-named  signs  the  diagnosis  re- 
mains obscure,  then  for  the  final  determination  an  exploratory 
puncture  in  the  area  of  the  dull  sound  must  be  resorted  to. 

ANOMALOUS    FORMS    OF    CROUPOUS    PNEUMONIA. 

Abortive  pneumonia  dift'ers  from  the  typical  only  by  its 
shorter  course;  the  febrile  period  lasts  about  three  days,  or  even 
only  one  day,  and  accordingly  the  local  symptoms  soon  disap- 
pear. In  the  event  of  incipient  vomiting  the  disease  may  be  mis- 
taken for  an  attack  of  gastric  fever,  but  such  an  error  is  avoided 
if  attention  be  directed  to  the  frequent  respiration,  cough  and  the 
results  of  physical  examination  of  the  chest. 

Much  greater  difficulties  in  diagnosis  are  presented  by  cases 
of  central  pneumonia — pncnuionia  centralis —  which  are  charac- 
terized by  late  appearance  of  the  physical  symptoms  of  hepatiza- 
tion of  the  lungs.    The  disease  begins  like  a  usual  croupous  pneu- 


314 


DISEASES   OF   RESPIRATORY    SYSTEM 


monia,  that  is,  with  violent  fever,  cough  and  hurried  respiration^ 
but  three  or  five  days  will  elapse  before  the  real  nature  and  situa- 
tion of  the  disease  may  be  learned.  It  is  supposed  that  the  in- 
flammatorv  focus  arises  primarily  in  the  center  of  the  lobe  of  the 
hmgs  and  therefore  remains  latent  until  the  hepatization,  increas- 
ing gradually  in  all  directions,  reaches  the  pulmonary  surface. 

It  is  significant  that  in  the  large  majority  of  cases  central 
pneumonia  is  localized  in  the  upper  lobes  and  that  the  majority 
of  apex-pneumoni.T  belong  to  the  latent  variety. 

Symptoms  which  lead  to  the  correct  estimation  of  latent 
pneumonia  consist  in  the  following : 

(i)  Dyspiicra,  characterized  by  frequent  respiration  (the 
ratio  between  the  breathing  and  tlie  ])ulse  is  I  :2),  with  dilata- 
tion of  the  nostrils  and  with  accentuation  in  the  expiration,  which 
is  frequently  accompanied  l)y  sighing. 

(2)  Short,  dry  painful  coiii^h. 

(3)  A  very  high,  continuant  type  of  fever. 

(4)  I'nilateral  pain  in  the  chest  or,  in  children  under  five 
years,  al)d(>minal  ])ain. 

If  children  do  not  themselves  complain  of  pain  (for  instance,, 
pectoral),  then  it  may  be  recognized  by  percussion;  the  child  be- 
gins to  cry  each  time  as  percussion  is  attempted  over  a  certain 
region,  for  instance  under  one  or  the  other  clavicle.  By  means 
of  this  symptom  we  may  often  determine  the  place  of  the  inflam- 
mation about  forty-eight  hours  previously  to  the  appearance  of 
dullness  or  bronchial  respiration. 

Still  more  diagnostic  difliculties  are  met  with  in  the  so-called 
CEREBRAL  PNEUMONIA — pueumonia  cerebralis — in  which,  as  if 
designedly,  everything  is  so  confused  as  to  force  the  physician 
to  an  error: 

(i)  From  the  very  commencement  of  the  disease,  together 
with  the  development  of  fever,  there  appear  cerebral  symptoms,, 
simulating;'  meningitis   (hence  the  name). 

(2)  We  deal  usually  with  apex-pneumonice,  running  lat- 
ently. 

(3)  Repeated  convulsions  and  somnolence  mask  the  mani- 
festations of  dyspnoea  and  cough. 

Barthez  and  Rilliet  distinguish  two  forms  of  cerebral  pneu- 
monia— the  convulsive  and  the  meninoeal. 


DISEASES    OF    RJCSIMRAIOKV    SVSl  i:.\I  315 

The  convulsive  form  of  cerebral  pneumonia  occurs  almost 
solely  in  small  children  about  two  years  old.  and  especially  in 
nurslings.  Like  any  other  pneumonia  this  form  ccjnies  on  sud- 
denly, with  violent  fever,  not  infrequently  with  vomiting,  and 
then  eclamptic  convulsions  appear  with  a  subsequent  semi-con- 
scious condition.  If  eclampsia  be  not  repeated,  then  the  som- 
nolence is  soon  over,  and  the  further  course  of  the  case  is  like 
that  of  a  common  jvieumonia  and,  if  you  like,  it  is  not  worthy 
of  the  name  of  "cerebral  pjieiiiiioiiia"  \  but,  unfortimately,  it  usu- 
ally happens  that  general  or  local  convulsions  are  repeated  for 
several  days  in  succession,  so  that  the  child  is  in  a  continuous 
state  of  sopor,  or  in  a  condition  similar  to  the  latter.  And  under 
the  influence  of  passive  hyper?emia  of  the  brain  (due  to  oli- 
structed  blood  circulation  caused  by  convulsions,  fever  and  pul- 
monary affection)  other  cerebral  symptoms  also  appear  in  the 
form  of  contracted  neck,  dilated  pupils  or  of  sluggish  reaction,, 
irregular  respiration  and  even  temporary  squint  and  paresis  of 
the  facial  muscles. 

Therefore  of  great  importance  in  the  diagnosis  of  such  cases 
is  the  character  of  the  fever,  namely,  the  constancy  of  very  high 
temperature.  If,  for  instance,  we  have  in  the  morning  and  even- 
ing a  temperature  of  40  degrees  C.  (  104  degrees  F.),  then  this 
fact  is  strongly  opposed  to  meningitis,  which  occurs  with  lower 
temperatures.  Furthermore  it  is  known  that  the  rapid  onset  (witli 
violent  fever  and  convulsions)  is  peculiar  only  to  acute  purulent 
meningitis,  which  does  not  appear  without  evident  reason,  but 
pertains,  for  instance,  to  otorrhoea,  contusion  of  the  head,  insoli- 
tion ;  thus,  the  absence  of  any  noticeable  cause  for  acute  ineni)i- 
gitis  serves  as  another  criterion  for  its  exclusion. 

And  then  again  the  duration  of  the  disease  is  also  important. 
If  in  meningitis  we  have  repeated  convulsions,  such  may  be  in- 
dicative of  the  beginning  of  the  end ;  the  patient  falls  into  a  deep 
stupor  of  which  he  does  not  become  free  until  death. 

Acute  meningitis  is  characterized  b\  the  early  onset  of  con- 
vulsions ending  with  death  in  three  or  Ave  days. 

In  pneumonia,  on  the  contrary,  there  are  no  prolouuil  changes 
in  the  brain,  and,  therefore,  if  convulsions  occur  even  at  intervals 
of  but  a  few  hours'  duration,  the  consciousness  of  the  patient 
begins  to  clear  readilv,  and  he  reacts  better  to  irritation  (see  also 


3l6  DISEASES   OF   RESPIRATORY    SYSTEM 

the  Semeiolog-y  of  Convulsions).  It  is  remarkable  that  the  cere- 
bral symptoms  usually  abate  as  soon  as  pneumonia  becomes  well 
determined.  Barthez  and  Sanne*  do  not  ascribe  any  diagnostic 
value  to  the  accelerated  breathing  which '  also  occurs  in  some 
cases  of  acute  meningitis  in  very  small  children. 

Of  more  importance  for  the  correct  estimation  of  the  case 
are  the  freciuent  cough  and  the  expiratory  character  of  the  res- 
piration (the  expiration  ends  with  sighing),  which  symptoms 
speak  positively  for  pneumonia  and  against  meningitis.  On  the 
other  hand,  the  appearance  of  paralyses  and  contractures  after 
convulsions  points,  in  their  opinion,  toward  inflammation  of  the 
cerebral  meninges. 

If  cerebral  symptoms  do  not  set  in  from  the  very  first  of 
pneumonia,  but  complicate  the  latter  in  its  further  course,  and 
if,  in  the  period  of  hepatization,  the  cerebral  symptoms  not  only 
do  not  abate,  but  even  increase,  then  one  may  believe  there  is  a 
complication  of  meningitis  and  pneumonia,  which  sometimes  oc- 
curs in  children,  although  very  rarely. 

In  the  inciiiui^col  loriii  which  is  peculiar  to  older  children 
(two  and  a  half  to  six  years  old)  convulsions  are  absent,  and 
after  the  incipient  vomiting  and  fever  symptoms  more  resembling 
typhoid  fever  than  meningitis  appear ;  the  patient  is  somnolent 
and  indififerent ;  his  tongue  is  dry  and  covered  with  brown  crusts ; 
the  faeces  and  urine  are  voided  involuntarily ;  delirium  at  night, 
and  sometimes  also  during  the  daytime.  Occasionally  also  symp- 
toms of  meningitis  arise  in  the  form  of  general  hypersesthesia, 
contracted  neck  and  constipation,  while  the  abdomen  is  somewhat 
sunken,  but  there  is  neither  retarded  pulse,  deep  inspirations,  nor 
change  of  the  color  of  the  face  characteristic  of  meningitis  (a 
sudden  redness  of  the  cheeks  alternating  with  pallor).*''' 


*Traitc  Clinique  ct  pratique  dcs  iiuiladics  dcs  citfants,  1884,  Vol.  I.,  p. 
744- 

**In  this  regard  Bergeron's  case  may  he  held  as  a  rare  exception.  This 
case  is  quoted  by  Cadet  (Tr.  din.  dcs  inal.  des  cnf.,  Vol.  I.,  1880,  page 
100).  The  disease  began,  in  a  child  two  and  one-half  years  old,  with  vom- 
iting (which  lasted  three  days),  fever  and  somnolence;  on  the  third  day, 
convulsions ;  on  the  fourth,  contracture  of  the  neck,  unconsciousness,  mas- 
ticatory movements  of  the  inferior  maxilla,  hypersesthesia  of  the  skin, 
Trousseau's  spots,  quick  change  of  the  color  of  the  face,  and.  what  is 
especially  noteworthy,  the  temperature  was  not  higher  than  39  degrees  C. 
(102.2  degrees  F.),  the  pu'se  was  retarded  (92),  as  well  as  the  inspirations 
(28).    On  the  fifth  day  consciousness  was  more  pronounced,  a  cough  ap- 


DISRASES   OF    RF.SIMRA  roKV    SYSTEM  3I7 

Hie  al)scnce  of  the  above-named  symptoms,  as  well  as  violent 
fever  and  the  sudden  onset,  entirely  exclude  tubercular 
meningitis. 

Resi'ardini^  typhoid,  the  too  early  appearance  of  somnolence 
and  of  other  so-called  typhoid  symptoms,  as  well  as  painful  cough- 
ing and  dyspnoea  with  the  dilatation  of  the  nostrils,  are  neither 
peculiar  to  it. 

Of  great  importance  in  the  difterential  diagnosis  between 
such  pneumonia  and  typhoid  is  the  initial  chill  in  older  children, 
or  a  convulsive  fit  in  smaller  ones.  Both  exclude  typhoid  almost 
positively.  It  is  obvious  that  doubt  may  last  long  only  in  central 
pneumonia. 

Wandering  pneumonia — pneumonia  migrans — is  character- 
ized by  the  inflammation  not  remaining  at  the  place  of  its  primary 
occurrence,  but  spreading,  like  erysipelas,  further  and  further, 
traveling  over  the  whole  lung,  so  that  the  disease  ma}-  become 
very  protracted. 

It  is  not  difficult  to  note  from  the  physical  examination  of 
the  chest  that  the  inflammation  resolves  in  the  earlier  afifected 
parts  and  develops  again  in  neighboring  ones.  The  fever  then 
may  be  markedly  irregular,  up  and  down,  signifying  by  this  the 
formation  of  a  new  focus  and  its  termination  ("oscillator}^,"  sac- 
cadirende,  pneumonia). 

However,  such  elevations  of  the  temperature  are  often  of 
such  short  duration  that  the}"  cannot  correspond  to  the  formation 
of  a  focus.  According  to  Cadet  de  Gassicourt  we  have  in  such 
cases  only  separate,  brief  pulmonary  hypergemi?e,  which  are  mani- 
fested either  by  some  dullness  and  crepitation  of  short  duration, 
or  even  by  no  objective  symptoms  at  all. 

According  to  Barthez  and  Sanne*  such  congestions  never 
protract  the  disease  longer  than  the  twelfth  day.  but  this  is  not 
correct,  as  seen,  for  instance,  in  the  temperature  table  on  page  326. 

As   such   pneumonia  oftener   occurs   in   la  grippe   we   shall 


peared,  and  a  pneumonic  focus  became  clear  in  the  lower  lobe  of  the  lung. 
On  the  sixth  day  all  cerebral  symptoms  disappeared  and  the  child  soon  re- 
covered. Until  the  fifth  day  the  diagnosis  of  pneumonia  could  not  be 
made,  especially  because  the  temperature,  the  pulse  and  the  respiration 
were  entirely  unusual  for  cerebral  pneumonia,  while  physical  examination 
was  not  followed. 

*Traitc  din.  ct.  prat,  de  )iial.  dcs  enf.,  Vol.  I.,  page  732. 


3l8  DISEASES    OF   KESI'IRATORV    SYSTEM 

g^ive  the  charts  when  we  speak  about  the  grippous  pneumoniae. 

Catarrhal  pneumonia — piiciiinoiiia  catarrhalis.  The  chief 
dififerences  between  catarrhal  and  croupous  pneumoniae  consist  in 
the  former  always  being  preceded  and  accompanied  by  symptoms 
of  catarrh  of  the  small  bronchi.  This  catarrh  by  spreading  to 
the  alveoli  causes  the  formation  of  small  inflammatory  foci,  which 
correspond  to  the  ramifications  of  the  bronchial  twigs,  hence  the 
name — broncho-pneumonia — or  lobular  indammation  of  the  lungs, 
in  distinction  from  the  lobar  variety,  which  is  peculiar  to  croup- 
ous penumonia.  In  the  further  course  separate  small  islets  of 
hepatization  may  coalesce  with  each  other,  forming  larger  foci  of 
hepatization — pseudo-lobar  or  generalized  lobular  pneumonia. 

Clinically  such  a  course  of  the  process  makes  itself  evident  in 
the  beginning  by  symptoms  of  febrile  capillary  bronchitis,  that  is, 
by  dyspnoea  and  the  presence  of  more  or  less  abundant  small  rales, 
especially  in  the  posterior  lower  portions  of  the  lungs.  According 
to  the  extension  of  the  inflammation  to  the  alveoli,  that  is,  accord- 
ing to  the  development  of  hepatization  of  the  lungs,  the  rales  be- 
come louder  and  louder — consonant  rales,  and.  fmally,  there  may 
appear  a  noticeable  dullness,  bronchial  respiration  and  broncho- 
phony. 

Ca])illary  bronchitis  is  usually  more  developed  in  the  pos- 
terior and  lower  portions  of  both  lungs,  while  emphysema  de- 
velops in  the  anterior  portion.  The  same  may  be  said  of  catarrhal 
pneumonia.  As  a  matter  of  fact,  the  latter  is  characterized  by  the 
appearances  of  hepatization  being  first  observed  on  the  back,  on 
both  sides  of  the  vertebral  column.  Consonant  rales  in  diffuse 
broncho-pneumonia  ma}-  be  present  in  these  places  for  a  long 
time  without  distinct  dullness ;  the  percussion  note  remains  clear 
or  it  obtains  a  tyuipanitic  timbre,  which  depends  upon  the  fact 
that  between  the  hepatized  foci  there  yet  remains  a  sufficient  quan- 
tity of  normal  pulmonary  tissue  to  prevent  the  exhibition  of  the 
dull  sound,  therefore,  it  happens  that  the  diagnosis  of  catarrhal 
pneumonia  in  its  beginning  is  far  more  determinable  by  ausculta- 
tion than  by  percussion. 

In  croupous  pneumonia,  on  the  contrary,  the  inflammation 
at  once  occupies  the  pulmonary  parenchyma,  without  the  prelim- 
inary affection  of  the  capillary  bronchi,  that  is,  the  development 
of  pneumonia  is  not  preceded  by  a  febrile  bronchitis.  The  focus 
of  inflammation  from  the  very  first  days  involves  an  entire  lobe 


DISKASKS    OF   RESPIRAIOKV    SYSTEM  3I9 

of  the  Inni^s,  or,  at  least,  its  larger  part,  so  that  very  soon  there 
appears  a  dull  note  over  the  region  of  the  affeeted  lobe,  and  on 
auscultation  bronchial  respiration  and  bronchophony  obtain. 

Regarding-  the  consonant  rales,  they  appear  only  in  the  period 
■of  resolution  of  the  croupous  inflammation  and  only  over  a  lim- 
ited space,  that  is,  not  passing  the  boundaries  of  the  inflamed 
lobe. 

The  further  course  consists  in  catarrhal  pneumonia  being 
mostly  bilateral ;  its  favorite  points  of  localization  are  the  pos- 
terior lower  portions  of  the  lungs ;  whereas,  croupous  pneumonia 
•oftener  alTects  only  one  lung,  without  preferring  the  lower  por- 
tions, as  it  involves  equally  often  the  upper  parts  as  well. 

As  to  the  course  of  the  temperature,  in  croupous  pneumonia 
the  fever  reaches  a  considerable  height  as  soon  as  the  first  even- 
ing, and  with  considerable  oscillations  keeps  the  same  maximum 
level  for  several  days,  terminating  with  marked  crisis ;  in  catar- 
rhal pneumonia  the  temperature  generally  does  not  reach  such 
a  height  and  only  at  times  rises  higher  than  40  degrees  C.  ( 104 
degrees  F.),  remaining,  however,  at  such  heights  but  briefly 
(from  a  few  hours  to  forty-eight  or  seventy-two  hours)  and  then 
falls  again ;  in  short,  the  temperature  chart  in  catarrhal  pneumonia 
is  distinguished  by  being  inconstant  and  varying  during  the 
twenty-four  hours,  when  it  terminates  by  lysis  which  lasts  three 
to  seven  days  and  longer. 

In  its  course  croupous  pneumonia  is  a  very  acute  disease ; 
it  sets  in  suddenly,  remains  at  a  certain  height  several  days  and 
after  five  to  eleven  days  terminates  as  quickly  as  it  started. 
Catarrhal  pneumonia,  however,  develops  gradually,  lasts  from 
two  up  to  several  weeks,  and  ends  slowly. 

The  cough  in  catarrhal  pneumonia  is  violent ;  the  patient, 
as  it  is  said,  coughs  "heavily" ;  the  dyspnoea  is  more  pronounced ; 
the  cyanosis  appears  quicker,  as  well  as  the  pufiiness  of  the  face 
and  feet. 

-\.n  essential  difference  is  also  noted  in  the  cetiology  ;  croup- 
ous pneumonia  affects  most  often  entirely  healthy  children,  thus 
appearing  as  a  primary,  entirely  independent  disease :  while 
catarrhal  pneumonia  is  a  secondary  affection  developing  from 
l)ronchitis.  being,  therefore,  observed  only  in  children  sick  with 
a  disease  which  is  associated  with  the  inflammatiiMi  of  the  bron- 


320  DISEASES    OF   RESPIRATORY    SYSTEM 

chi ;  therefore  most  often  occurring  in  measles,  whooping'-cough, 
croup  (especially  in  small  children  under  four  years  of  age)  and 
in  rachitis. 

If  catarrhal  pneumonia  becomes  protracted  for  several  weeks 
then  it  may  be  accompanied  by  the  formation  of  bronchiectasiae, 
and  then,  upon  examination  of  the  lungs,  cavernous  symptoms  are 
obtained  in  the  form  of  large,  consonant  rales,  of  a  metallic  timbre 
of  the  percussion  note,  and  cavernous  respiration,  so  that  the  ques- 
tion arises,  with  what  kind  of  cavities  in  the  lungs  have  we  to 
deal — with  caverns  of  tubercular  (caseous)  origin  or  with  bron- 
chiectasicC  ? 

This  question  only  leads  to  the  differentiation  of  a  protracted 
catarrhal  pneumonia  from  a  tubercular  one. 

Physical  symptoms  alone  are  insufficient  for  the  decision 
of  this  point,  because  in  both  cases  they  will  be  the  same ;  besides 
this,  both  diseases  most  often  arise  after  measles  and  whooping- 
cough,  both  arc  accompanied  by  irregular  fever  and  exhaustion, 
and  both  last  weeks  and  even  months. 

Characteristic  of  tul)ercular  disease  of  the  lungs  in  adults 
are  the  parts  aft'ected,  namely,  the  upper  portions ;  but  in  children 
tuberculosis  does  not  select  the  apices. 

The  examination  of  the  sputum  for  bacilli  and  elastic  fibers 
is  mostly  impossible,  because  children  under  six  years  of  age,  in 
whom  catarrhal  pneumonia  most  often  occurs,  do  not  expectorate. 

Likewise  the  temperature  chart  does  not  give  sufficient  in- 
formation upon  which  to  base  the  diagnosis,  as  in  tuberculosis 
it  is  of  the  same  irregular  type  as  in  protracted  catarrhal  pneu- 
monia. 

Briefly,  the  differential  diagnosis  of  these  two  processes  is 
very  difficult,  notwithstanding  that  the  prognosis  depends  upon 
it,  as  pulmonary  tuberculosis  almost  always  ends  fatally,  while 
catarrhal  pneumonia  often  turns  to  convalescence,  even  when  pro- 
tracted for  months  and  accompanied  by  considerable  wasting  and 
physical  signs  of  pulmonary  caverns   (bronchiectasice). 

Tubercular  pneumonia  may  be  supposed  with  almost  com- 
plete probability  in  case  the  patient  exhibits  other  symptoms  of 
tuberculosis,  for  instance,  in  the  form  of  chronic  disease  of  the 
bones,  joints  or  glands,  or  if  the  chronic  inflammatory  process 
involves  the  pulmonary  apices,  the  patient  being  above  the  age 


oisKASKs  OF  UKSi'iRAr()k\'  svs'i  i:m  321 

of  six  years,  and  the  pulmonary  lesion  itself  of  ehronic  eoiu'se. 
In  older  children  tuhereular  afifections  of  the  lungs  differ  from 
the  same  disease  in  adults  perhaps  only  by  the  quicker  occurrence 
of  a  fatal  termination. 

On  the  contrary  if  the  disease  began  in  the  form  of  acute 
catarrhal  pneumonia  (  for  instance,  after  measles)  in  a  child  previ- 
ously in  good  health,  and  especially  under  three  years  of  age; 
if  the  process  involves  the  posterior,  lower' i)t)rtions  of  the  lungs; 
then  non-tubercular  catarrhal  pneumonia  may  be  supposed  and 
thus  a  favorable  termination  may  be  hoped. 

It  is  self-evident  that  there  cannot  be  a  complete  certainty 
regarding  the  absence  of  tuberculosis  during  a  protracted  pneu- 
monia for  the  reason  that  in  the  presence  of  some  tubercular  pre- 
disposition, which  is  so  often  met  with  in  rachitic  and  scrofulous 
children,  tuberculosis  may  complicate  the  original  disease. 

A  marked  likeness  to  catarrhal  pneumonia  is  presented  by 
cases  of  hypostatic  pneumonia.  The  similarity  consists  in  the 
hypostasis  being  usually  bilateral  and  occupying  the  posterior, 
lower  portions  of  the  lungs ;  in  the  beginning  a  weakened  respira- 
tion with  small  rales  is  noted,  and,  later,  symptoms  of  a  genuine 
pneumonia — dull  sound,  bronchial  respiration  and  bronchophonv. 
The  difference  is  based  not  so  much  on  the  symptoms,  as  on  the 
aetiology ;  hypostatic  pneumonia  requiring  for  its  development 
two  conditions ;  a  weakened  heart-activity  and  a  prolonged  re- 
cumbent posture  on  the  back,  and  therefore  it  obtains  most  often 
during  severe  cases  of  febrile  diseases,  especially  of  typhoid. 

Crepitant  rales  in  the  posterior  lower  portions  of  the  chest 
may  be  noted,  upon  deep  inspiration,  in  children  in  whom  the 
heart  acts  well  and  whose  general  condition  is  satisfactory,  yet 
have  been  compelled  for  some  reason  to  remain  for  a  long  time 
in  bed.  This  crepitation  differs  from  that  of  inflammatory  origin 
by  its  disappearance  after  two  or  three  deep  inspirations,  depend- 
ing not  upon  the  presence  of  fluid  in  the  alveoli,  but  upon  their 
walls  being  glued  together,  so  to  say,  and  then  separated  by  the 
entrance  of  air.  In  one  case  in  a  girl  eight  years  of  age  I  ob- 
served this  condition  on  the  tenth  day  of  a  very  mild  scarlet  levei  ; 
there  was  neither  fever,  dyspnoea,  nor  cough,  so  that  there  could 
not  be  any  doubt  as  to  the  nature  of  the  crepitation.  This  case 
proves  how  early  such  a  crepitation  occurs  in  children.    The  same 


322  DISEASES   OF   RESl'IRATORV    SYSTEM 

may  also  be  observed  after  absorption  of  an  abundant  pleuritic 
exudate,  and  may  be  noted  a  long  time  (weeks)  after  the  child 
decidedly  improves  and  is  up,  yet  the  compressed  lung  remaining 
in  the  condition  of  atelectasis. 

In  very  sick  patients  the  small  and  large  moist  rales  may  be 
indicative  of  piilnwnary  oedema,  that  is,  of  efifusion  of  serous  liquid 
into  the  pulmonary  alveoli.  This  condition  is  chiefly  characterized 
by  the  wide  distribution  of  the  rales,  the  percussion-note  being 
clear,  and  by  dyspnoea  rapidly  setting  in,  as  well  as  by  these 
symptoms  appearing  either  during  the  course  of  a  general  dropsy 
already  developed  (diseases  of  the  kidneys,  cardiac  lesions),  or 
as  a  death-symptom  in  diliferent  acute  diseases  in  the  period  of 
cardiac  collapse. 

From  capillary  bronchitis  pulmonary  oedema  differs  by  the 
rapid  onset  and  spreading  of  the  rales,  and,  especially,  by  the 
sputum,  (if  only  the  patient  expectorates  the  latter),  which  in 
pulmonary  oedema  is  very  abundant,  thin  and  frothy. 

One  may  find  in  the  text-books  hints  by  which  to  distinguish 
catarrhal  pneumonia  from  capillary  bronchitis  complicated  with 
atelectasis  of  the  pulmonary  alveoli — ^atelectasis  pulmonum.  It 
is,  for  instance,  mentioned  that  atelectasis  does  not  cause  fever, 
that  the  dull  sound  and  weakened  respiration  or  appearances  of 
consolidation  rapidly  disappear  after  the  patient  makes  a  few  deep 
inspirations,  etc. ;  but  all  these  signs  are  purely  theoretical,  be- 
cause in  such  an  atelectasis  fever  is  always  present,  although  de- 
pending not  upon  the  atelectasis,  but  on  the  accompanying  capil- 
lary bronchitis.  It  is  difficult  to  notice  the  disappearance  of  the 
dull  sound  after  deep  inspiration  inasmuch  as  atelectasis  usually 
develops  in  small  children  in  whom  it  is  difficult  to  induce  deep 
inspirations.  It  is  sufficient  to  say  that  atelectasis  may  be  with 
certainty  suspected  in  any  capillary  bronchitis  and  in  catarrhal 
pneumonia  in  small  children. 

Congenital  atelectasis  indeed  runs  without  fever,  being  char- 
acterized by  a  dull  sound  and  weakened  vesicular  respiration  in 
some  certain  portions  of  the  chest,  or  by  crepitant  rales  due  to 
separated  pulmonary  alveoli.  As  to  the  islet-like  atelectasis  this 
becomes  recognized  not  from  the  results  of  the  physical  examina- 
tion of  the  chest,  but   from  the  history   (the  child  was  born  in 


DISliASKS    OF    Ri:Sl-IK.\l()RV    S^S^I■;M 


323 


I? 

op' 


324  DTSEASES    OF    RESriRATORV    SYSTEM 

the  condition  of  asphyxia),  (jf  the  weak,  screammg  voice,  fre- 
quent respiration  and  cyanosis. 

Pneumonia  during  endemic  la  grippe  has  a  different 
course  dependent  upon  whether  it  comphcates  a  case  of  la  grippe 
running-  with  constant  fever,  or  a  protracted  case  with  an  atypical 
fever. 

In  the  former  case  pneumonia  in  its  physical  signs  entirely 
corresponds  to  croupous  ])neumonia  with  which  it  is  often  con- 
fused;  dull  note,  hronchial  respiration,  hronchophony  and  the 
exaggerated  fremitus  develop  rajMdly  and  involve  at  once  a  whole 
pulmonary  lobe,  the  upper  or  lower  one — this  is  immaterial.  After 
a  few  days  the  disease  ends  almost  by  crisis,  in  short,  everything 
seems  as  in  croui)()Us  ])iu'um(>nia,  yet  there  is  a  difference  con- 
sisting ill  the  following:  typhical  croupous  pneumonia  affects 
healthy  children,  the  grip])ous,  however,  those  w^ho  had  already 
been  sick  several  days  with  la  grippe,  that  is,  it  alzvays  appears 
several  days  after  the  appearance  of  rhinitis,  coiii^h  and  fever^ 
most  often  between  the  fifth  and  the  ninth  days.  In  this  respect 
it  resembles  the  so-called  central  pneumonia,  the  majority  of 
cases  of  which  Ijelong.  in  my  opinion,  to  la  grip])e,  especially  if 
we  deal  with  pneumoni?e  of  the  apices.  The  temperature  in 
croupous  pneumonia  is  distinguished  b}'  the  constancy  of  the 
high  degrees  and  the  very  rapid  termination  from  the  fifth  up  to 
the  eleventh  day.  In  grippous  pneumonia  the  temperature,  al- 
though it  also  may  be  a  constant  one,  yet  in  the  majority  of  cases 
it  makes  considerable  excursions  u])  and  down,  with  a  termina- 
tion not  so  rapid  (approximately  in  thirty-six  to  seventy-twa 
hours). 

The  course  of  the  temperature  is  sometimes,  in  the  first  days 
of  the  disease  before  the  development  of  pneumonia,  irregular  to 
such  a  degree — so  typical  of  la  grippe — that  croupous  pneumonia 
cannot  even  be  thought  of.  We  reproduce  here  two  charts,  one 
belonging  to  a  ten-months-old  girl  and  the  other  a  seven-year-old 
boy. 

A  girl  aged  ten  months  became  sick  on  February  22d,  with 
rhinitis,  cough  and  fever.  From  the  24th  to  the  28th  the  child 
felt  better,  but  from  March  ist  fever  reappeared,  of  an  in- 
termittent type.  From  the  sixth  of  March  the  temperature  is 
noted  on  ihe  chart  (Fig.  32). 


DISI'-. ASI'.S    Ol'-    RE 


>>S'li:.M 


325 


The  objective  exainination  of  llie  luniks  np  lo  ilu-  Iwelfth 
day  of  the  disease  was  nei^ative.  the  couL;h  havini,'-  heen  incon- 
siderable, but  would  increase  every  time  aloiii:;  with  the  period  of 
temperature.  'JMie  resf)iration  was  from  sixty  to  eighty.  Tumor 
of  the  spleen  k'us  absent.  Ouinine,  from  two  to  four-and-a-half 
grains,  pro  die.  did  not  influence  the  lein])erature.  On  the  twelfth 
day  dullness  was  noticed  under  tlie  rii^ht  clavicle,  with  bronchial 
respiration  and  bronchophony.  Convalescence,  under  an  indilter- 
ent  treatment,  on  the  twenty-second  day. 

The  chart  in  this  case  resembles  very  much  that  of  inter- 
mittent  fever   the   more   .so    in   that    elevations   occurred    in    the 


■nHBBHaBllBBin 

^■■■■■■■■■1  ■■ 

■■■■■■■nni  ■■ 

^■■flmnmiu 

gmnnHHHiinni 

■■■WHnHHWHBII 

nimnHBHHHmi 

■■■■■BBHHB  nn 

Fig.    ;iT, —  Temperature   curve   in   pneumonia. 

mornino- ;  but  the  al)Ove-mentioned  peculiarities,  marked  by  italics, 
as  well  as  the  uselessness  of  quinine,  and  the  bei^inning-  of  the 
coryza,  seemed  significant  enough  of  la  grippe. 

In  the  second  case  a  boy  seven  years  old  liecame  sick  with 
la  grippe  together  with  his  three  sisters.  The  inflammation  of 
the  right  apex  became  evidenced  on  the  niiUh  day  of  the  disease, 
and  the  final  crisis  followed  on  the  elexenth  day  (big.  33). 

In  the  diagnosis  of  such  cases  the  ])resence,  in  a  given  family, 
of  other  cases  of  la  grii)pe,  as  well  as  tlie  age  of  the  patient,  is  of 
importance. 

Lobar  pneumoniae  in  nurslings  and  in  children  under  two 
years  of  age  occur  mostly  because  of  la  grip])e.  while  in  elder 
children  primary  pneumonise  oftcner  occurs. 

Pneunioni(C   complicating   cases   of   la   gi"'p])e    niiniing   with 


Z26 


1-)I.SEASES   OF   RESPIRATORY    SYSTEM 


DISKASKS    OF    Ki:Sl'iK.\  TOkV    SYSTEM  X^Z"] 

atypical  fever  dilTer  from  the  jji't'ccdin^-  forms  by  a  vcr}-  irrciLi^ular 
and  prolonged  course:  l)ecaiisc  of  the  repeated  formation  of  new 
inflammatory  foci,  the  develojiment  of  the  latter  Ix^ing-  accom- 
panied in  each  instance  by  exacerbation  of  the  fever,  and  their 
resohition  l)y  decline  of  the  temiieratiu'e,  so  that  a  most  irregular 
course  of  the  fever  is  obtained.  In  comparing  cases  of  central 
pneumonia  during  the  acute  course  of  la  grippe  with  those  of  la 
grippe  showing  an  atypical  fever,  the  pneumonia  corresponds 
with  the  migrans  form. 

A  typical  example  of  such  a  course  of  the  disease  is  repre- 
sented by  the  following  case : — 

A.  D.,  aged  two  years,  entered  the  hospital  on  account  of 
cough  of  ten  days'  duration,  with  fever.  During  the  first  two 
days  of  the  patient's  stay  in  the  hospital  nothing  but  a  moderate 
bronchitis  could  be  detected  ;  on  the  third  da\-  there  was  a  slight 
dullness  in  the  area  of  the  right  apex,  over  the  clavicle,  and 
bronchial  respiration.  With  every  day  the  hepatization  became 
clearer  and  clearer  and  spread  all  over  the  lungs  during  the  fol- 
lowing weeks  (Fig.  34).  Thus,  during  thirty  days  there  were 
eleven  marked  and  rapid  elevations  of  the  temperature  and  as 
many  falls;  some  of  the  latter,  as  on  the  i6th,  iQth,  24th,  29th 
and  34th  days  reached  36.5  degrees  C.  (97.7  degrees  F.),  that  is, 
they  similated  a  real  crisis,  the  more  so  that  sinndtaneously  there 
also  appeared  other  symptoms  of  crisis  in  the  form  of  perspira- 
tion and  small  consonant  rales  at  the  place  of  hepatization. 

Here  also  belongs,  in  my  opinion,  the  case  of  intermittent 
pneumonia  which  I  observed,  together  with  Dr.  \'erevkin,  who 
described  the  same  in  X'olume  XXV.  of  Med.  Obocr.  (Russian) 
page  ion.  The  case  is  that  of  a  girl  five  years  old.  The  pneu- 
monia appeared  first  of  all  in  the  lower  lobe  of  the  left  lung,  and 
later  it  traveled  over  the  right  side,  involved  each  lobe  separately 
and,  finally,  affected  the  whole  left  lung,  terminating  with  the 
formation  of  an  abscess,  after  the  opening  of  which,  through  the 
bronchi,  a  complete  recovery  followed.     (Fig.  35.) 

It  is  impossible  to  differentiate  by  the  olijective  signs  a  wan- 
dering croupous  pneumonia  (provided  such  a  form  in  reality 
occurs)  from  a  wandering  grippous  one.  If  the  disease  started 
directly  in  the  form  of  ])neumonia,  with  chills  and  fever,  in  a 
healthy  child,  then  one  ma\'  rather  su])iK)se  the  croupous  form  ; 


u^ 


DISEASI'LS    OF    KKSl'l  R  ATOKV    SYSTEM  329 

if,  however,  ])neumnnia  appeared  in  a  patient  sntTerin_i;-  from  la 
grippe,  then  the  i^rippons  variety. 

If  la  grippe  occurs  with  involvement  of  the  small  hronchi, 
then  it  may  give  rise  to  the  development  of  a  typical  catarrhal 
pneumonia,  that  is.  with  localization  hehind.  on  IxDth  sides  of 
the  vertebral  cohnnn.  with  small  consonant  rales,  without  notice- 
able dullness,  but  with  considerable  dyspnoea,  as  in  capillary  bron- 
chitis. A  protracted  pneumonia  in  la  grippe  (catarrhal  or 
migrans)  may  be  mistaken  f(^r  a  tubercular  one.  For  the  correct 
estimation  of  the  case  it  is  important  to  know  the  beginning  of 
the  disease  (snuffles)  and  absence  of  hereditary  disposition  to 
tuberculosis  ;  further,  in  favor  of  la  grijipe  may  also  be  the  exist- 
ence of  an  epidemic,  the  season,  and  the  absence  of  bacilli  in  the 
sputum,  (if  there  is  sputum). 

Inflammation  of  the  pleura.  Plciirifis.  Pleurisy  may 
be  dry  or  exudative.  ( )f  dry  pleurisy  we  have  a  pathognomonic 
sign  in  the  friction-rub  which,  although  it  may  be  likened  to  some 
small  moist  rfdes,  yet  differs  from  them  by  being  heard  during 
both  inspiration  and  expiration,  while  the  crepitant  rales  occur 
•only  in  expiration.  Furthermore,  the  friction-rub  is  usually 
"heard  over  a  very  limited  area,  increases  upon  pressure  with  the 
.stethoscope  and  does  not  change  after  the  patient  coughs.  One 
must,  however,  notice  that  the  friction-rub  in  childhood,  espe- 
cially in  small  children,  is  far  from  being  observed  so  often,  in 
pleurisy,  as  in  adults. 

Pleuritic  exudate — is  characterized  by  the  occurrence  of  a 
dull  sound  on  one  side  of  the  chest,  Urst  of  all  behind,  belozv,  and 
then  sf^readiiii^  upicards  and  forwards,  but  in  such  a  way  that 
the  upper  border  is  somewhat  higher  on  the  back  than  on  the  front 
of  the  chest. 

The  respirator}-  murmur,  the  lungs  being  incompletely  com- 
pressed, remains,  in  the  area  of  the  dull  note,  vesicular  but  weak- 
ened. If  the  exudate  be  more  considerable,  if  between  the  bronchi 
and  the  chest-wall  there  be  a  more  uniform,  airless  medium,  then 
.bronchial  respiration  appears,  but  not  so  loud  as  in  croupous  pneu- 
monia ;  and  if  the  exudate  is  so  abundant  that  even  the  bronchi 
are  compressed,  then  the  respiratory  murmur  disappears  entirely, 
at  least  in  the  lower  posterior  portions.  If  there  be  bronchial 
respiratifMi.   then    Ju-i>uchof^hony   nia\'   also  be   iircsent.   but    roeal 


330  DISEASES    OF   RESPIRATORY    SYSTEM 

fremitus  is  aki^ays  zveaketied.  It  is  always  easier  to  note  the 
diminution  of  the  respiraton,-  murmur  and  vocal  fremitus  if  they 
be  compared  first  over  the  place  of  the  dull  sound  then  with 
neig'hboring-  portions  of  the  chest  located  above,  which  give  a 
clear  sound. 

If  the  exudation  fills  out  the  entire  half  of  the  chest,  then 
still  other  characteristic  signs  and  symptoms  make  themselves^ 
evident :  the  patient  suffers  from  dyspnoea,  which  increases  upon 
assuming  the  recumbent  posture  and  still  more  upon  laying  on  the 
healthy  side,  and  therefore  the  patient  is  compelled  to  lie  on  the 
affected  side.  The  pressure  of  the  fluid  leads  (i)  to  the  inter- 
costal spaces  on  the  affected  side  becoming  even;  (2)  displace- 
ment of  the  heart  to  the  side  opposite  that  having  the  exudation ; 
in  left-sided  pleurisy  the  apex-beat  is  felt  on  the  right  side  of 
the  sternum;  in  right-sided,  on  the  left  axillar}-  line;  the  liver  is 
displaced  downwards  and  its  lower  border  may  sometimes  be- 
felt  on  the  level  of  the  navel ;  the  displacement  of  the  diaphragm 
on  the  left  side  is  shown  by  the  dislocation  of  the  spleen  down- 
wards and  by  the  disappearance  or  diminution  of  Traube's  semi- 
lunar space  (normally  the  tympanitic  sound  of  the  stomach  and 
bowels  reaches,  in  children,  on  the  anterior  axillary  line  the 
eighth,  and  on  the  mammillary  line  the  sixth  interspace). 

The  affected  side  of  the  chest  dilates  on  inspiration  much 
less  than  the  well  side,  and  upon  measurement  its  circumference- 
is  found  two  or  three  centimeters  larger. 

In  the  beginning  of  its  development  pleurisy  occurs  with- 
fever,  but,  contrary-  to  croupous  pneumonia,  seldom  begins  witb 
violent  temperature,  vomiting  and  convulsions.*  The  tempera- 
ture usually  rises  gradually  to  about  39  degrees  C.  ( 102.2  degrees 
F.).  continuing  with  more  considerable  morning  variations,  and 
ends  by  lysis  not  earlier  than  in  two  or  three  weeks :  but  where 
there  is  an  abundant  exudation  or  a  purulent  one,  it  becomes  pro- 
tracted for  about  six  weeks  or  longer. 

In  the  commencement  of  pleurisy  one  seldom  succeeds  in- 
hearing  the  friction-rub  of  the  pleura,  which  disappears  accord- 
ing to  the  increase  of  the  amount  of  the  exudative  fluid.     Far 


*Several  such  cases  have  been  described  by  Henoch   (p.  389,  3rd  ed. 
1887). 


DISEASES   OF   RESPIRATORY    SYSTEM  33I 

oftener  this  may  be  heard  during  the  period  of  absorption  when 
the  absence  of  pain  permits  the  child  to  take  deeper  inspirations. 
The  cough  appears  in  pleurisy  from  the  very  first  and  lasts  until 
the  end.  At  first  it  is  dry,  short  and  painful ;  later  on  more 
friable. 

In  some  cases  the  cough  is  absent  altogether. 

Briefly,  pleuritic  symptoms  in  children  are  the  same  as  in 
adults ;  and  the  more  abundant  the  exudation,  the  easier  is  the 
diagnosis.  Only  in  the  beginning  of  the  disease  may  there  appear 
some  difficulty,  when  the  exudation  is  not  yet  large  (reaching, 
for  instance,  the  half  of  the  scapula),  and  pleurisy  may  thus 
be  confused  with  pneumonia.  Touching  the  dififerentiation  of 
these  two  diseases  the  reader  is  referred  to  page  310. 

In  some  cases  pleuritic  exudation  developes  latently  being  from 
the  very  first  not  only  without  a  noticeable  fever  (usually  the 
latter  is  present,  but  it  is  insignificant,  and  therefore,  over-looked), 
but  also  without  cough,  and  the  w^iole  sickness  manifests  itself 
by  symptoms  of  progressively-developing  exhaustion :  the  parents 
relate  that  the  child  for  the  last  month  has  grown  thin  and  pale, 
that  he  eats  but  little  and  cannot  walk  long,  because  he  feels  tired 
very  soon,  and  dyspnoea  appears,  but  cough  is  either  absent  or 
very  insignificant.  If,  in  view  of  the  last  fact,  the  physician  ex- 
cludes pulmonary  disease  and  does  not  hold  it  necessary  to  ex- 
amine the  chest,  then  the  pleurisy  will  remain  unrecognized  for 
an  indefinite  time,  notwithstanding  its  diagnosis  is  very  easy,  as 
in  the  great  majority  of  such  cases  the  parents  consult  the  physi- 
cian when  the  exudate  is  quite  extensive  and,  perhaps,  reaches  the 
clavicle. 

If  the  latent  pleurisy  be  accompaned  by  fever,  then  this 
disease  is  mistaken  either  for  typhoid  or  malarial  fever,  depend- 
ing upon  the  character  of  the  pyrexia.  I  remember  a  case  of 
such  a  pleurisy  in  a  four-year-old  girl  in  whom  the  exudate  oc- 
cupied the  whole  half  of  the  chest,  nevertheless  was  not  recog- 
nized, only  because  the  attending  physician  thought  it  was  malaria 
and  thus  regarded  it  useless  to  perform  percussion  of  the  chest, 
as  the  girl  did  not  cough,  the  respiratory  murmur  having  been 
heard  well  on  both  sides. 

\\'ith  a  case  of  pleuritic  exudation  the  physician  must  al- 
wavs  think  of  the  character  of  the  exudate,  that  is,  if  this  be  serous 


332 


DISEASES   OF   RESPIRATORY    SYSTEM 


or  purulent,  because  upon  this  point  depends  the  prognosis  as 
well  as  the  treatment. 

The  diagnosis  of  purulent  exudations  is  not  always  easy ;  it 
may  be  based  on  general  as  well  as  on  local  symptoms.  If  in  a 
patient  suffering  with  pleuritic  exudation  the  fever  assumes  the 
intermitting  type,  with  daily  chills  and  profuse  perspiration,  and 
if  simultaneously  there  be  noted  the  quick  development  of  wasting 
and  paleness,  then  the  exudation  is  positively  purulent ;  further- 
more if  the  fever,  in  the  case  of  such  an  exudation,  always  has 
a  pyseniic  character,  then  the  diagnosis  should  not  be  difficult ; 
yet  as  repeated  chills  and  siveats  may  he  absent,  despite  a  purulent 
exudation,  and  the  fever  of  the  same  remittent  character  as  in 
serous  exudations,  then  one  must  resort  to  other  methods  for 
determining  the  peculiarities  of  the  exudation.  In  this  diagnostic 
direction  the  cause  of  the  disease,  the  age,  the  quantity  of  the 
exudate,  the  duration  of  the  disease  and  local  symptom^  may  be 
of  value. 

Regarding  the  causes  it  is  known  that  pleurisy  after  scarlet 
fever  is  very  often  i)urulent :  and  the  same  may  be  said  of  pleuri- 
sies in  persons  sufifering  with  i)y?emia. 

[Empyema  very  often  complicates  pneumonia;  this  being 
pro'«  en  by  many  observers,  among  whom  may  be  named  Blaker*, 
Bythell*'',  Bogart*''^'  and  Cotton****.  The  latter  studied  i8o 
cases  of  empyema  in  children  under  twelve  years  of  age,  and  con- 
cludes that  it  usually  follows  lobar  pneumonia  or  is  due  to  some 
pneumonic  infection. — Earle.] 

The  i^urulent  character  of  the  exudation  is  the  more  probable 
the  }  ounger  the  child  and  the  greater  the  quantity  of  the  exudate. 
Therefore,  it  is  always  suspicious  if  the  exudation  in  a  child 
reaches  the  clavicle ;  and  if  the  child's  age  is  under  two  years, 
then  the  purulent  character  of  the  exudate  is  more  than  probable. 

We  do  not  know  with  certaint}-  how  long  the  fever  ma>-  last 
in  serous  exudation.  It  is  only  positively  known  that  abundant 
exudates  may  be  absorbed  even  after  the  fever  has  been  of  many 
weeks  duration,  but  such  cases  do  not  prove  anything,  as  it  is 


^Progressive  Medicine,  1904,  iNIarch,  p.  254. 

**Med.  Chronicle,  November,  1902. 

***Bogart,  Annals  of  Surgery,  April,  1899. 

****Cotton.     Boston  Med.  ajid  Surg.  Journal.  July  17,  1902. 


DISEASES    OF   RICSIMRAIORV    SYSTEM  333 

undn-.iV.ted  that  in  childhood  cvcmi  entirely  i)urnknt  exudations 
sometimes  become  al>sorhed.  This  has  been  proven  by  numerous 
cases  of  empyema  which  have  disappeared  after  one  puncture, 
while  it  is  known  that  it  is  not  always  possible  to  remove  the 
whole  exudative  contents  of  the  chest  by  means  of  a  mere  punc- 
ture, even  when  associated  with  aspiration. 

According'  to  Cadet  de  Gassicourt"  if  the  absorption  of  the 
exudate  does  not  begin  after  the  thirtieth  day,  and  if  the  tem- 
perature shows  great  variations,  then  the  exudation  is  almost 
positively  purulent.  This  rule  has,  of  course,  exceptions,  but  for 
the  majority  of  cases  it  is  true,  and  therefore  it  may  be  of  use 
as  an  indication  for  performing  an  exploratory  puncture. 

As  to  the  local  symptoms  there  are  three  that  positively  point 
toward  a  purulent  exudation,  however,  in  the  majority  of  cases 
they  appear  late.    These  symptoms  are : 

(i)  Qidema  of  the  subcutaneous  tissues  on  the  affected  side 
of  the  chest. 

(2)  Formation  of  a  burrowing  abscess,  which  shows  an  im- 
minent opening  through  the  chest-wall. 

(3)  The  sudden  elimination,  with  cough,  of  great  amounts  of 
pus  due  to  opening  of  the  empyema  through  the  lungs. 

Regarding  the  burrowing  abscess,  of  course,  not  each  abscess 
appearing  on  the  chest-w-all  denotes  an  empyema ;  the  latter  is  to 
be  suspected  only  in  case  the  patient  does  not  suffer  from  caries 
of  the  vertebral  column  or  ribs  and  if  a  simple  abscess  of  the 
cellular  tissue  can  be  eliminated. 

In  all  these  non-empyemic  cases  percussion  of  the  aft'ected 
side  of  the  chest  gives  a  clear  sound. 

If  after  a  general  and  local  examination  the  purulent  char- 
acter of  the  exudation  be  doubted,  then  for  a  final  decision  of 
the  question  the  exploratory  puncture  by  means  of  a  Pravatz's 
hypodermic  syringe  must  be  resorted  to. 

It  is  quite  difficult  to  determine  the  most  suitable  time  for 
this  method  of  examination,  because  much  depends  upon  the 
peculiarity  of  the  case,  as  w-ell  as  upon  the  physician's  views.  It 
is  true  that  when  guided  by  these  varying  circumstances  one 
physician  will  undertake  an  exploratory  puncture  earlier  than  an- 

*Traitc  din.  d.  mal.  de  I'cnf.     Vol.  I.,  page  372. 


334  DISEASES   OF   RESPIRATORY    SYSTEM 

otlier,  or  later,  dependent  upon  tliose  symptoms  which  will  ap- 
pear doubtful  to  this  or  that  physician.  I  personally  hold  it  neces- 
sary to  make  a  puncture  in  the  following  cases : 

(i)  When  the  exudation  fills  the  entire  half  of  the  chest 
and;  especially,  if  we  deal  with  a  child  under  two  years  of  age, 
while  the  time  elapsing  since  the  beginning  of  the  disease  has  no 
importance,  because  the  exudation  may  be  purulent  even  from 
the  very  first. 

(2)  If  during  the  fourth  week  from  the  beginning  of  the 
disease  the  fever  is  not  inclined  to  abate,  and  especially  in  case  it 
assumes  an  intermittent  type. 

(3)  II  after  the  thirtieth  day  there  is  noticed  no  absorption 
of  the  exudate,  even  if  the  temperature  be  normal,  as  the  absence 
of  fever  does  not  exclude  purulent  pleurisy. 

It  is  self-evident  that,  if  there  are  chills,  sweats,  and  other 
above-mentioned  signs  of  purulent  exudation,  the  indications  for 
a  puncture  are  urgent. 

One  must  not  think  that  the  exploratory  puncture  always 
gives  pure  pus  in  the  case  of  purulent  exudation.  It  sometimes 
happens  that  only  turbid  serous  liquid  will  be  withdrawn  (the  tur- 
bidity, as  the  microscope  shows,  depends  upon  pus  corpuscles), 
and  then,  post  mortem,  it  will  be  found  that  the  walls  of  the  pleural 
cavity  are  lined  with  a  thick  sheath  of  dense  pus.  As  a  matter 
of  fact,  if  the  purulent  exudate  is  not  very  dense  the  blood-ele- 
ments easily  sink  to  the  bottom  or  become  attached  to  the  walls, 
and  a  serous  fluid  is  formed  above.  On  this  account  empyema 
may  be  diagnosed  if  upon  exploratory  puncture  there  is  obtained 
not  a  purulent,  but  only  a  cloudy  (because  of  the  presence  of 
pus-corpuscles)  serous  fluid. 

One  might  tliink  it  would  be  easy  to  distinguish,  by  means 
of  bacterioscopic  examination  of  the  exudation,  a  tubercular 
pleurisy  from  any  other,  but  it  has  been  found  that  the  matter 
is  not  so  simple.  In  the  case  of  exudations  the  bacterioscopic 
examination  is  almost  of  no  value,  as  in  most  cases  such  exuda- 
tions appear  sterile.  In  purulent  exudations  pneumococci  or 
streptococci,  or  other  different  purulent  microbes,  are  found,  but 
almost  never  tubercle  bacilli.  [Bythell  studied  forty  cases  of 
empyema  bacteriologically  and  found  the  pneumo-bacillus  alone 
in  sixty-five  per  cent  (twenty-six  cases)  ;  in  nine  cases  the  pneu- 


DISEASES    OF   RESPIRATORY    SYSTEM  335 

Tno-bacillus  was  mixed  with  other  microbes,  in  two  cases  strepto- 
coccus alone  was  found,  in  one,  streptococcus  with  staphylococ- 
cus, in  one  streptococcus  with  pneumo-bacillus  and  in  one  Fried- 
lander's  bacillus  with  the  staphylococcus.*  Nearly  the  same  results 
have  been  obtained  by  Koplik,  who  found  that  empyema  was  due 
to  pneumo-bacillus  in  sixty-nine  per  cent,  and  to  tubercle  bacilli 
in  seven  per  cent'^"^. — Earle.]  This  observation,  however,  has 
Ijroughi  out  an  important  fact,  that  if  the  bacteriological  examina- 
tion of  the  purulent  pleuritic  exudation  proves  negative,  that  is, 
■does  not  determine  any  microbes,  then  the  tubercular  origin  of 
such  an  empyema  is  very  probable.  For  the  purpose  of  a  final 
■decision  of  the  question  one  may  inject  some  pus  into  the  abdomi- 
nal cavity  of  a  guinea-pig,  which  will  become  affected  with  tuber- 
culosis after  four  or  five  weeks  in  the  event  of  the  tubercular 
•origin  of  the  pus. 

Some  resemblance  to  pleuritic  exudation  is  presented  by  cases 
of  HYDROTHORAX  (accumulation  of  transudative  fluid  in  the 
pleural  cavities)  and  pneumothorax  (accumulation  of  air  in  the 
pleural  cavity). 

The  common  symptoms  of  pleuritic  exudation  and  hydro- 
thorax  consists  in  the  appearance  of  a  dull  sound  in  the  lower 
portions  of  the  chest,  the  upper  boundary  of  which  rises  higher 
and  higher  according  to  the  development  of  the  disease.  Over  the 
area  of  dullness  a  weakened  respiration  and  feeble  vocal  fremitus 
are  heard. 

The  differences  are  the  following : 

(i)  The  accumulation  of  a  transudate  in  the  pleural  cavity 
is  never  an  isolated  condition,  but  is  always  accompanied  by  a 
transudation  at  other  places,  most  often  in  the  cellular  tissue  and 
abdominal  cavity. 

(2)  Hydrothorax  is  almost  always  bilateral,  although  it  may 
"be  developed  more  on  one  side  (the  side  on  which  the  patient 
lies). 

(3)  The  cause  of  the  dropsy  may  be  found  either  in  diseases 
of  the  kidneys  (most  often),  or  in  disease  of  the  heart,  or  in 
hydrsemia  due  to  chronic  enteritis. 


*Med.  Chronicle,  November,  1902. 
**Med.  News,  September  13.  1902. 


336  DISEASES    OF   RESPIRATORY    SYSTEM 

(4)  The  upper  lx)rder  of  the  dull  sound  in  the  erect  posture  of 
the  patient  is  horizontal  in  hydrothorax ;  or  on  change  of  position 
the  border  of  the  dull  sound  changes  also. 

(5)  Hydrothorax  occurs  without  fever,  without  pain  in  the 
side  and  dyspnoea  (provided  the  amount  of  fluid  is  not  consider- 
able), as  well  as  without  cough. 

The  common  symptoms  in  hydrothorax  and  pneumothorax 
consist  in  the  change  of  the  shape  of  the  chest ;  the  afifected  side 
dilates  but  little  upon  respiration,  it  is  larger  than  the  well  side; 
the  intercostal  spaces  are  even ;  the  respiratory  murmur  is  weak- 
ened, as  well  as  the  fremitus ;  the  neighboring  organs  are  dis- 
placed ;  the  patient  complains  of  dyspnoea  and  is  compelled  to  lie 
on  his  side.  The  essential  difference  consists  in  the  results  of  per- 
cussion— in  exudation  a  dull  sound  is  obtained ;  in  pneumothorax 
a  clear  one,  tympanitic  with  a  metallic  timbre.  Upon  auscultation 
there  is  either  absence  of  the  respiratory  murmur,  or  amphoric 
respiration.  If  pneumothorax  develops  because  of  rupture  of  the 
empyema  through  the  lungs,  then  air  occupies  the  place  of  the 
exudative  fluid,  and  in  the  upper  portions  of  the  chest  a  clear  or 
tympanitic  note  is  obtained,  which  may  cause  a  beginner  to  sup- 
pose that  the  lung  which  was  previously  compressed  is  beginning 
to  dilate  and  the  patient  is  on  the  way  to  recovery.  But  such  an 
error  is  promptly  avoided  if  heed  be  given ;  ( i )  to  the  fact  that 
dyspnoea  not  only  did  not  diminish,  but  even  perhaps  increased ; 
and  (2)  that  over  the  area  of  the  clear  sound  respiratory  murmurs 
are  not  heard. 

DISEASES  OF  THE  LUNGS  CHARACTERIZED  BY  THE 
SECRETION  OF  FCETID  SPUTUM. 

A  foetid  sputum  denotes  either  the  existence  of  bronchiectatic 
cavities  in  which  the  secretion  of  the  mucous  membrane  becomes 
stagnant  and  decomposes ;  or  a  putrid  bronchitis  (bronchitis 
putrida)  or  pulmonary  gangrene.  The  sputum  in  all  these  cases 
presents  the  peculiarity  of  being  very  foetid  and  shows  on  stand- 
ing a  very  marked  division  into  three  layers ;  the  upper,  frothy ; 
the  middle  one,  fluid,  quite  clear,  transparent ;  and  the  lower  one, 
purulent,  rich  with  detritus  and  crystals  of  margaric  acid.  Of 
an  especially  repulsive  gangrenous  odor  is  the  sputum  in  pulmon- 
ary gangrene,  wherein  the  breath  also  is  very  foetid. 


DISEASES   OF   RESIMRAIORY    SYSTEM  337 

It  is  further  characteristic  of  bronchicctasice  that  the  patient 
at  times  expectorates  (especially  in  the  morning'  on  the  change 
of  position)  an  abtmdant  quantity  of  quite  fluid,  fcetid  sputum. 

The  general  aspect,  general  condition  and  fever  depend  upon 
the  l)asic  disease.  If  the  dilatation  of  bronchi  is  accompanied,  for 
instance,  by  interstitial  pneumonia  (the  issue  of  croupous  or 
catarrhal — measles — pneumonia)  then  the  general  condition  is 
quite  satisfactory,  but  fever  may  be  entirely  absent.  The  same 
happens  in  cases  of  development  of  bronchiectasise  in  a  collapsed 
lung,  following  an  old  pleuritic  exudate,  on  the  contrary,  in 
bronchiectasije  during  a  tubercular  pneumonia  there  will  be  fever 
and  exhaustion. 

Regarding"  the  physical  signs,  these  may  be  manifold  and  their 
character  dependent  upon  whether  the  bronchiectasia;  are  sur- 
rounded by  a  dilated  or  a  hepatized  lung.  In  the  former  case 
the  patient  presents  symptoms  of  chronic  bronchitis,  while  in 
hepatization  of  the  lungs  cavernous'  symptoms  are  obtained  ;  am- 
phoric respiration  or  loud  bronchial  breathing,  bronchophony, 
large  consonant  rales  and,  on  percussion,  a  tympanitic  note,  some- 
times with  a  metallic  timbre.  All  these  characteristic  physical 
symptoms  disappear  in  case  the  caz'ity  is  tilled  zvith  a  secretion, 
appearing  again  after  a  lit  of  coughing  with  elimination  of  a  great 
quantity  of  sputum.  Of  course,  the  same  symptoms  may  also 
be  present  in  tuberculous  cavities,  but  then  there  will  be  bacilli  and 
perhaps  elastic  fibers  in  the  sputimi. 

\^'e  speak  here  only  of  chronic  bronchiectasi?e  (  because  foetid 
sputum  is  peculiar  only  to  the  latter) ,  commonly  met  with  in 
interstitial  pneumonije  which  usually  proceed  without  fever  and 
remain  stationary  for  a  long  period,  therefore,  if  symptoms  of 
cavities  are  observed  in  a  patient  whose  general  condition  is  com- 
paratively good  and  who  suffers  from  an  abimdant  secretion  of 
foetid  sputum,  then  one  may  positively  conclude  that  he  is  not 
affected  with  tuberculosis,  but  with  bronchiectasise  as  a  restilt 
of  interstitial  pneumonia. 

If  the  bronchiectatic  cavities  are  so  small  that  no  physical 
signs  of  cavities  are  present,  then  it  is  impossible  to  differentiate 
from  foetid  bron.chitis  because  the  latter  is  distinguished  by  the 
absence  of  a  periodical  secretion  of  abundant  sputum  with  the 
subsequent  appearance  of  cavernous   symptoms. 


338  DISEASES   OF   RESPIRATORY    SYSTEM 

The  foetid  sputum  during  pulmonary  gangrene  differs  from 
that  in  bronchiectasise  by  its  stronger  odor  and  by  the  fact  that  it 
is  not  difficult  to  detect  the  presence  of  remains  of  pulmonary  tis- 
sue in  the  form  of  black  tufts  which  when  examined  under  water 
appear  in  the  form  of  irregular  lumps.  The  microscopical  ex- 
amination may  easily  show  that  these  masses  have  alveolated 
structure,  but  elastic  fibers  cannot  be  found  as,  in  gangrene  of  the 
lungs,  they  occur,  strange  to  say,  very  rarely. 

In  order  to  more  readily  detect  these  remains  of  pulmonary 
tissue  the  sputum  must  be  left  to  stand  and  the  deposit  from  the 
floor  of  the  vessel  must  be  taken  for  the  examination.  (A  minute 
description  of  the  microscopical  peculiarities  of  the  sputum  can 
be  found  in  Eichhorst's  Text-book  of  Practice  of  Medicine,  Vol- 
ume I.) 

The  general  condition  always  suffers  severely  in  pulmonary 
gangrene,  the  fever  not  infrequently  is  accompanied  by  chills  and 
profuse  sweating,  and  collapse  soon  comes  on. 

Regarding  the  physical  symptoms,  these  vary,  depending 
upon  the  conditions.  In  the  case  of  a  diffuse,  rapidly-spreading 
gangrene,  symptoms  of  hepatization  of  the  lungs  predominate,  but 
in  circumscribed  gangrene  with  decomposition  of  the  pulmonary 
tissue,  there  are  cavernous  symptoms. 

Before  the  diagnosis  of  bronchiectasiae  or  pulmonary  gan- 
grene is  made  from  the  fcetid  sputum,  other  causes  of  foetid  secre- 
tion must  be  excluded,  for  instance,  some  diseases  of  the  mouth, 
as  noma,  stomacace,  ozaena  (foetid  rhinitis),  some  cases  of  retro- 
pharyngeal abscess  and  especially  sanious  exudate  from  an  old 
pleurisy  opening  through  the  lungs. 


DISEASES    OF   THE    NERVOUS    SYSTEM 

We  shall  first  mention  the  semeiotic  meaning  of  some  symp- 
toms which  are  of  general  importance,  and  then  proceed  to  the 
differential  diagnosis  of  separate  diseases  most  often  met  with 
in  childhood. 

THE  SEMEIOLOGY  OF  HEADACHE. 

Headache  occurs,  to  be  sure,  in  children  of  any  age,  but  as 
a  subjective  symptom  it  often  remains  unrecognized  even  in 
children  who  can  talk,  because  under  five  years  of  age  they  seldom 
complain  of  headache  at  a  certain  point,  wherever  it  may  be. 
Headache  in  small  children  can  be  recognized  only  if  the  same 
be  very  severe  and  causes  the  child  to  manifest  it  by  often  grasp- 
ing his  head  with  the  hands,  pulling  himself  by  the  hair,  constant- 
ly moving  his  head  to  this  or  that  side  or  contracting  the  fore- 
head. For  the  production  of  such  symptoms,  however,  it  is  nec- 
essary that  the  headache  be  very  severe. 

Headache  due  to  considerable  elevation  of  temperature  of  the 
body  usually  does  not  reach  such  a  degree  as  to  be  evidenced  by 
objective  signs,  we  find  it  almost  exclusively  in  cerebral  diseases 
and  inflammation  of  the  middle  ear,  and  both  these  diseases  must 
be  first  of  all  be  thought  ol  in  treating  with  a  child  who  cries 
much,  is  restless  and  grasps  the  head  with  the  hands. 

Headache  in  children  over  five  years  of  age  occurs  very  often, 
and  for  diagnostic  purposes  all  cases  coming  under  this  descrip- 
tion may  be  divided  into  acute  and  chronic. 

In  the  classification  of  acute  headache  we  include  those  cases 
in  which  headache  appears  suddenly,  continues,  for  instance,  a 
few  days  and  wherein  the  patient  previously  never  suffered  from 
similar  headache.  The  absence  of  fever  does  not  exclude  acute 
headache. 

To  chronic  headache  we  refer  all  cases  of  the  so-called 
habitual  headpains,  whether  these  be  constant  or  irregularly  re- 
peated. 


340  DISEASES    OF    THE    NERV'OUS    SYSTEM 

Acute  headache  differs  from  the  chronic,  aside  from  the 
history,  by  being  always  accompanied,  with  some  rare  exceptions, 
by  elevation  of  temperature. 

If  the  patient  suffers  with  acute  headache  associated  with 
elevation  of  temperature,  then  the  main  question  to  be  decided 
consists  in  whether  the  pain  depends  upon  fever,  or  appears  as  a 
symptom  of  a  beginning  meningitis.  In  the  first  two  or  three 
days,  and  sometimes  c\'en  longer,  this  question  cannot  always  be 
decided.  Wc  investigate,  first,  the  character  of  the  headache, 
second,  the  intensity  of  the  fever,  and.  third,  the  concomitant 
symptoms. 

The  headache  in  meningitis  and  acute  hydrocephalus  is  nota- 
bly severe  and  constant,  that  is,  does  not  show  intervals,  and 
its  intensity  does  not  correspond  to  the  range  of  the  temperature ; 
while  headache  depending  simply  upon  fever  is  usually  not  severe, 
unless  the  temperature  is  very  high  (more  than  40  degrees  C. — 
104  degrees  F.).  If  the  child  complains  of  headache  only  when 
questioned  about  the  same,  then  it  is  probably  not  a  meningitis 
(we  say  "probably"  because  insignificant  headache  does  not  entire- 
ly exclude  meningitis,  especially  its  tubercular  form)  ;  if,  how- 
ever, he  throws  alx>ut  because  of  headache,  the  latter  being  the 
chief  complaint,  then  meningitis  is  the  more  probable,  and  still 
more  so  the  lower  the  temperature.  A  very  violent,  unaccustomed 
headache  with  a  temperature  about  38  or  38.5  degrees  C.  (100.4 
or  101.3  degrees  F.)  is  almost  pathognomonic  of  meningitis.  If  a 
severe  headache  be  observed  along  with  a  temperature  of  40 
degrees  C.  ( 104  degrees  F.),  then  it  is  of  no  especial  value  for  the 
diagnosis  of  meningitis  even  when  accompanied  by  vomiting, 
because,  first,  both  may  occur  during  any  febrile  condition,  and, 
second,  violent  fever  almost  excludes  tubercular  meningitis,  that 
is,  the  form  which  most  often  occurs  in  childhood. 

With  reference  to  the  simple  purulent,  and  cerebro-spinal 
meningites,  in  which  a  temperature  of  40  degrees  C.  (104  degrees 
F.)  is  not  a  rarity,  one  should  bear  in  mind  that  in  these  forms 
(usually  rare)  other  cerebral  symptoms  very  soon  set  in  which 
clear  up  the  diagnosis. 

We  have  just  said  that  a  very  severe  headache  is,  to  some 
extent,  characteristic  of  meningitis,  but  it  does  not  follow  that 
it  is  always  of  such  a  character  in  this  malady.     The  absence  of 


DISEASES    OF    TJIE    M:kVOUS    SYSTEM  34: 

pronounced  headache  excludes  only  acute  purulent  meningitis 
(meningitis  simplex,  s.  purulenta),  but  it  does  not  contraindicate 
a  beginning  acute  hydrocephalus  (meningitis  tuberculosa). 
Again  the  onset  of  tubercular  meningitis  is  not  to  remain  un- 
recognized because  a  severe  headache  does  not  obtain.  As  a 
matter  of  fact  the  degree  of  headache  in  acute  hydrocephalus 
depends  very  much  upon  the  rapidity  of  development  of  the 
disease;  the  headache  will  be  the  severer,  the  quicker  the  disease 
sets  in  {increased  pressure  in  the  cerebral  cavity),  but  as  in  tuber- 
cular meningitis  hydrocephalus  sometimes  develops  quite  slowly. 
then  the  headache  also  may  not  be  severe. 

As  to  the  concomitant  symptoms,  the  leading  one  among  them 
is,  of  course,  vomiting,  which  occurs  in  all  cases  of  meningitis, 
acute  purulent,  as  well  as  in  subacute  or  tubercular.  //  the  patient 
did  not  vomit  even  a  single  time  from  the  appearance  of  head- 
ache, the  first  twenty-four  or  forty-eight  hours,  then  one  may 
say  almost  zcith  certainty  tliat  he  has  no  meningitis.  Cases  of 
meningitis  without  vomiting,  although  they  may  occur,  are  great 
rarities.  We  have  already  mentioned  the  character  of  cerebral 
vomiting.  The  diagnostic  significance  of  vomiting  coincident 
with  headache  is  lessened,  however,  by  its  occurring  also  during 
diseases  other  than  meningitis  and  especially  under  the  influence 
of  repugnant  medicines. 

Another  symptom  very  important  in  its  connection  with 
headache  is  a  retarded  and  irregular  pulse.  This  symptom  is  the 
more  pronounced  the  less  the  fever  and  the  older  the  child.  In 
acute  purulent  meningitis  with  a  temperature  of  40  degrees  C. 
(104  degrees  F.)  the  pulse  not  infrequently  remains  regular  and 
quickened ;  but  instead  of  this  in  similar  cases  there  rapidly  comes 
on  unconsciousness  and  general  convulsions. 

Other  symptoms  of  meningitis,  which  will  be  discussed  later 
on,  appear  earlier. 

Headache  independent  of  any  cerebral  lesion,  but  associated 
with  elevation  of  temperature,  is  of  no  diagnostic  value,  with  the 
exception,  perhaps,  that  together  with  other  symptoms  of  general 
malaise  it  aids  questions  in  the  history,  namely  when  the  child 
started  to  be  feverish.  Severe  headache  without  elevation  of  tem- 
perature or  with  insignificant  fever,  but  in  the  presence  of  snuffles, 
ma}'  depend  upon  extension  of  the  calarrh  to  the  frontal  sinuses; 


342  DISEASES    OF    THE    NERVOUS    SYSTEM 

in  such  a  case  the  pain  is  locahzed  in  the  forehead. 

Headache  is  of  particular  meaning  when  it  appears  in  a  child 
suffering  with  acute  nephritis.  It  is  immaterial  if  there  is  fever 
simultaneously,  or  the  temperature  remains  normal ;  headache  in 
acute  nephritis  is  always  a  suspicions  sign  on  account  of  be- 
ginning urmnia,  and  especially  in  case  it  be  accompanied  by 
vomiting. 

In  estimating  the  significance  of  headache  of  acute  character 
one  should  bear  in  mind  that  it  may  be  localized  in  the  soft  cover- 
ing of  the  skull,  for  instance  in  rheumatism,  or  in  circumscribed 
inflammatory  foci.  The  location  of  headache  in  such  cases  is 
determined  by  palpation,  as  inflammatory  pain  increases  upon 
pressure  on  the  affected  part.  In  rheumatism  of  the  galea  apo- 
neurotica  the  pain  is  felt  not  only  in  the  head,  but  also  frequently 
spreads  over  the  muscles  of  the  neck  (torticollis)  and  increases 
upon  raising  the  eye-brows  and  wrinkling  the  forehead. 

The  history  being  certain,  and  if  the  headache  appears  in 
several  members  of  the  same  family,  it  is  easy  to  diagnose  fumes 
(CO-poisoning).  Headache  in  such  cases  is  often  accompanied 
by  vomiting  and  general  weakness.  It  is  known  that  the  same 
symptoms  may  also  depend  upon  alcohol  (wine)  poisoning. 

Chronic  headache  may  depend  either  upon  any  coarse 
anatomical  changes  of  the  brain,  in  the  form,  for  instance,  of 
chronic  hydrocephalus,  tumor  of  the  cranial  cavity,  etc.,  or  upon 
the  affection  of  other  organs,  or  it  appears  as  independent. 

The  diagnosis  of  symptomatic  headache  connected  with 
chronic  disease  of  the  brain  is  based  upon  the  simultaneous  exist- 
ence of  other  cerebral  symptoms,  as  vomiting,  mental  debility, 
paralyses  and  pareses,  especially  of  the  eye-muscles  (strabismus, 
ptosis,  amblyopia)   and  local  or  general  convulsions. 

Headache  depending  upon  chronic  lesion  of  the  brain  is 
characterized  by  its  pronounced  tendency  to  aggravations.  In 
the  case  of  circumscribed  diseases  of  the  cerebral  meninges 
(abscess,  syphilis)  persistent  headaches  appear  limited  to  a  certain 
area.  Among  the  characteristic  symptoms  of  such  a  headache 
may  be  also  included  the  fact  that  in  some  cases  it  increases  upon 
percussion  of  the  corresponding  point  of  the  skull. 

Chronic  headache,  which  does  not  depend  upon  diseases  of 


DISEASES    OF    THE    NERNoUS    SYSTEM  343 

the  brain  and  its  nuMiibranes  occurs  in  childhood  quite  often  and 
may  depend  upiMi  various  causes. 

Migraine  should  be  mentioned  first  of  all  of  this  lar.c^e  group, 
the  chief  cause  of  which  is  heredity.  Aligraine  differs  from  any 
other  headache  by  appearinc;  in  paroxysms,  occupying  onlv  one 
side  (the  left)  of  the  head  and  usually  terminating  after  a  few 
hours  with  vomiting  and  then  sleep.  In  slight  cases  there  is 
usually  no  vomiting,  but  it  is  quite  sufficient  for  the  diagnosis  that 
some  paroxysms  are  accompanied  by  vomiting.  As  objective 
signs  of  migraine  in  children  there  are  pallor  of  the  face,  general 
languor  and  sometimes  yawning.  If  such  symptoms  occur  at 
times  in  a  child  who  is  in  all  other  respects  a  healthy  one,  and 
each  time  the  paroxysm  ends  in  a  few  hours  with  vomiting  and 
sleep,  then  migraine  may  be  recognized  even  in  children  who  can- 
not talk. 

Attacks  of  headache  in  migraine  appear  at  irregular,  and 
more  or  less  prolonged,  intervals  of  from  a  couple  of  days  or 
weeks  up  to  whole  months;  almost  never  docs  inii^raiiic  occur 
two  days  in  succession ,  and  in  general  one  may  say  that  if  in  a 
child  headache  be  repeated  several  days  in  succession,  or  even 
every  week,  then  this  is  most  probably  not  a  pure  migraine. 

Attacks  of  migraine  appear  either  without  any  certain  cause^ 
or  under  the  influence  of  physical  or  mental  fatigue ;  but  heredi- 
tary predisposition  must  be  held  as  the  first  factor  (in  the  history 
migraine  is  usually  mentioned  in  some  of  the  parents).  [Gould* 
regards  the  diseases  of  the  eye  as  the  most  frequent  cause  of 
migraine.  He  says  in  this  connection  :  I  am  sure  that  migraine 
occurs  more  often  in  childhood  than  it  is  supposed.  Gowers  goes 
so  far  as  to  say  that  one-third  of  all  cases  begin  from  the  fifth  to 
the  tenth  year.  It  all  depends  on  the  existence  of  ametropia  and 
the  amount  of  study,  reading,  etc.,  carried  on.  I  have  had  a 
large  number  of  school-children  afflicted  with  the  malady  in  vari- 
ant and  typical  forms.  One  little  boy  I  particularly  remember 
whose  astigmatism  for  years  increased  about  0.5  degrees  every 
few  months,  was  each  time  relieved  of  his  intense  vomiting  by 
a  change  of  glasses  until  the  compensation  of  the  higher  astigma- 


*Gould :  "The  History  and  .^Stiology  of  Migraine."     lour.  Amcr.  Med. 
Assoc,  January,  1904,  p.  241. 


344  DISEASES    OF    THE    NERVOUS    SYSTEM 

tism  a^ain  became  impossible. — Earle.  ]  This  cause  is  so  con- 
stant that  if  headache  develops  in  a  child  whose  parents  never 
suffered  with  migraine,  then  this  circumstance  alone  makes  it 
doubtful  if  in  any  given  case  the  migraine  is  an  idiopathic  one, 
that  is,  an  independent  neurosis ;  it  is  more  probable  that  such  a 
migraine  will  prove  to  be  either  a  reflex-occurrence  (diseases  of 
the  nose),  or  a  symptomatic  headache  (anaemia,  diseases  of  the 
brain,  etc.)- 

]t  is  also  quite  characteristic  of  migraine  that  headache  al- 
most always  may  be  relieved  by  taking  antipyrin  (as  many  grains 
as  the  patient  is  years  old),  or  antifebrin  (one-half  such  quan- 
tities), although  I  do  not  intend  to  altogether  claim  that  these 
remedies  are  useless  in  headache  of  other  origin. 

The  general  condition  of  nutrition  in  children  disposed  to 
migraine  may  remain  excellent. 

Migraine  ma\'  easily  be  confused  with  neuralgia  of  the 
supRAORi'.iTAL  NERVE  (ncuralgia  snpraorbitalis),  in  w"hich  pain 
is  also  felt  unilaterally,  but  the  essential  differences  are,  first,  that 
the  patient  denotes  the  supraorbital  area  as  the  location  of  pain, 
provided  he  can  localize  his  sensations,  and,  second,  in  all  cases 
of  supraorbital  neuralgia  the  pain  increases  upon  pressure  on  the 
supraorbital  opening. 

Supraorbital  neuralgia  is  comparatively  often  of  malarial 
origin,  returning  in  such  a  case  regularly  every  day,  or  every 
other  day.  at  the  same  hour ;  therefore,  in  all  cases  of  intermit- 
tent headache  in  a  child  one  should  think,  first  of  all,  of  neuralgia 
supraorbitalis. 

Besides  migraine,  there  occurs  in  children  yet  another  class 
of  nervous  headaches  v.hich  are  repeated  either  daily,  or  with 
some  irregular  intervals.  These  headaches,  sometimes  hardly 
noticeable,  sometimes  very  severe,  have  no  special  localization ; 
the  patient  complains,  depending  upon  the  case,  of  the  forehead, 
parietal  region,  occiput  or  the  whole  head. 

Here  we  find,  for  instance,  headaches  which  depend  upon 
general  iiialiiiitritioii.  The  diagnosis  rests  upon  the  exclusion  of 
other  causes  of  headache  and  the  presence  of  symptoms  of  general 
anaemia  (pallor  of  the  skin  and  mucous  membranes,  loss  of  ap- 
petite, wasting,  restless  sleep,  irritability)  or  of  chlorosis,  which 
differs    from   a   common    infantile   anaemia   liy    much    more   pro- 


DISEASES    OF    THE    NERVOUS    SYSTEM  3J5 

nounced  pallor  (waxy  paleness)  of  the  skin  and  mucous  mem- 
branes as  well  as  by  the  age  of  the  patients.  A  common  anaemia 
is  usually  met  with  in  children  five  to  twelve  years  of  age,  in 
females  as  well  as  in  males,  but  chlorosis  occurs  almost  exclusive- 
ly in  females  after  eight  to  twelve  years.  Headache,  depending 
•only  upon  chlorosis,  but  not  upon  any  other  causes,  is  also  peculiar 
in  yielding  readily  to  iron  treatment. 

In  connection  with  headache  in  an  anjemic  child  one  should 
bear  in  mind  that  ana."mia  itself  may  depend  upon  some  certain 
■cause  without  the  removal  of  which  the  treatment  will  be,  of 
course,  useless.  Among  such  causes  are  included  catarrh  of 
the  stomach,  intestinal  worms,  nephritis  (uraemia)  and  masturba- 
tion. 

In  the  opinion  of  some  authors  juasturbation  may  be  su>- 
pected  if  the  headache  is  localized  in  the  occiput.  But  it  is  better 
to  be  guided  by  other  signs,  as  open  meatus  penis,  tardy  reaction 
■of  the  cremaster  upon  tickling  the  inner  surface  of  the  thigh, 
suspicious  spots  on  the  garments  and  the  bed-clothing.  As  a 
very  valuable  sign,  often  met  with  in  masturbators,  Renzi  points 
■out  the  disappearance  of  the  knee-jerk*.  It  is  also  characteristic, 
to  some  extent,  that  such  victims  are  inattentive,  cannot  concen- 
trate their  attention  very  long,  while  older  children  usually  be- 
come too  pious.  { They  have  heard  of  the  harm  of  masturbation 
and  not  feeling  strong  enough  for  a  struggle  against  the  same 
•they  have  recourse  to  religious  influence  and  surroundings.) 

A  peculiar  nervous  headache  occurring  in  weak,  anaemic 
children,  as  well  as  in  entirely  healthy  ones  7vith  good  nutrition 
and  living  in  the  best  hygienic  environment,  is  known  under  the 
name  of  school-headache  or  headache  due  to  over-exertion,  and 
-likewise  headache  due  to  growth  ( "cephalagie  de  croissance,"  of 
French  authors).  This  suflering  is  noted  in  youths  from  ten  up 
to  fourteen  or  sixteen  years  old.  Such  a  headache,  like  any  other 
nervous  headache,  is  confined  either  to  the  forehead,  or  to  the 
whole  head,  being  often  combined  with  symptoms  of  neuras- 
thenia; the  child  becomes  irritable  or  sad,  snivelling,  etc.,  but  the 
main  characteristic  feature,  peculiar  of  all  cases  of  school-head- 
ache, consists  in  the  inability  to  do  mental  zvork.  In  mild  cases 
■headache  appears  only  during  forced  mental  occupation,  and  in 


*See  Med.  Obozr.     1888,  No.  11. 


346  DISEASES    OF    THE    NERVOUS    SYSTEM 

severe,  well-pronounced  cases  even  at  the  slightest  exertion,  not 
excluding  even  pleasant  mental  exercise,  as,  for  instance,  the- 
reading  of  an  interesting  novel. 

In  these  cases  headache  is  persistent  from  day  to  day  during 
many  months,  and  to  be  cured  requires  the  complete  cessation 
of  all  study,  at  least  for  half  of  a  year,  otherwise  it  may  last 
for  many  years,  until  the  period  of  rapid  growth  is  overcome  by 
maturity. 

School-headache  is  most  easily  confused  with  that  cephalalgia- 
which  often  occurs  in  children  and  depends  upon  abnormal  refrac- 
tion and  accommodation,  and  which  can  be  cured  by  nothing  but 
corrective  glasses.  Such  cause  of  headache  is  not  unusual,  as  may 
be  seen  from  Bickerton's  papers*  wherein  one  thousand  patients 
with  refractive  errors  being  examined,  headache  was  a  prominent 
feature  among  the  patients'  complaints  in  2//  cases  (27.7  per 
cent).  Of  the  greatest  importance  in  this  regard  is  hypermetropia 
with  astigmatism.  The  similarity  of  headache  dependent  upon 
eye-strain  with  school-headache  consists,  first,  in  both  appearing 
only  during  mental  occupation  and  disaj^ixviring  during  rest,, 
second,  by  sparing  neither  weak  nor  strong  children. 

Chronic  headache  may  also  depend  upon  diseases  of  the  nose; 
while  a  visible  rhinitis,  that  is,  a  discharge  from  the  nose,  may 
even  be  absent,  the  impermeability  of  the  nasal  passages  being 
sufficient.  Quite  a  good  many  cases  of  persistent  headaches  cured. 
by  means  of  proper  treatment  of  the  nose  have  been  described; 
for  example  I  am  reminded  of  Menier's  case**.  The  headache 
was  in  a  nine-year-old  boy ;  had  continued  for  two  years,  and 
was  cured  by  the  removal  of  tumors  of  the  nasal  mucous  mem- 
brane. 

If  the  headache  appears  in  a  child  after  brisk  exertion  or 
during  hot  weather,  and  is  relieved  after  a  nose-bleed,  then  it 
proves  the  same  to  be  dependent  upon  congestion  of  the  brain. 

Eichhorst  called  attention  to  the  appearance  of  headache,, 
sometimes  accompanied  with  vomiting,  under  the  influence  of 
temporary  albuminuria,  which  sometimes  occurs  in  youths  with- 

^Abstract  in  "Vratch,"  1S88,  page  680. 
**"Vratch,"  1888,  N.  22. 


DISEASES    OF    THE    NERVOUS    SYSTEM  347 

out  any  noticeable  cause.  Albuminuria  may  last  weeks  and 
months,  and  during  this  time  there  often  appear  attacks  of  head- 
ache, sometimes  connected  with  general  debility,  weakening  of 
the  memory,  irritability  and  even  convulsions. 


SEMEIOLOGY    OF    GENERAL    CONVUL- 
SIONS. 

When  we  have  to  deal  with  a  child  in  whom  there  have  ap- 
peared .e:eneral  convulsions  of  tonic  or  clonic  character,  manifest- 
ing themselves  mainly  by  irregular  twitchings  of  the  muscles  of 
the  face  or  extremities,  together  with  loss  of  consciousness,  it  is 
sometimes  very  hard  to  determine  the  cause  of  such  convulsions, 
and  not  infrequently  the  physician  when  he  sees  the  patient  the 
first  time  is  unable  to  state  more  than  the  mere  fact,  and  unwill- 
ingly satisfies  himself  with  the  sentence  that  the  patient  has  an 
eclamptic  fit,  or  the  so-called  childhood  eclampsia. 

The  attack  of  general  convulsions,  whatever  the  cause  may 
be,  is  nearly  always  the  same;  in  single  cases  the  difference  is  only 
that  in  one  patient  the  fit  lasts  longer  and  the  convulsions  them- 
selves are  severer,  in  another  they  are  shorter ;  in  one  case  the 
fits  follow  each  other  with  more  or  less  brief  intervals,  so  that 
during  twenty-four  hours  more  than  twenty  fits  of  general  con- 
vulsions may  be  counted,  and  in  the  other  case  everything  ends 
with  a  single  attack.  The  essential  difference  may  be  expressed 
also  by  the  course,  namely  that  in  some  patients  the  fit  of  con- 
vulsions appear  only  once,  and  then  does  not  reappear  during 
the  whole  life,  while  in  other  patients  the  convulsions  occur  from 
different  causes  (in  children  suft'ering  from  laryngismus  stridulus, 
for  instance,  such  a  cause  is  often  some  excitement,  etc.,  in  other 
•cases  convulsions  are  repeated  in  the  beginning  of  each  severe 
febrile  disease,  etc.),  or  even  without  noticeable  causes  during 
the  first  two  years  of  life,  or  even  during  the  whole  life 
(epilepsy). 

Each  single  attack  of  general  convulsions  usually  begins 
with  a  short  period  of  tonic  convulsions  (the  child  stops  breath- 
ing, his  eyes  are  turned  upwards  under  the  upper  eye-lids,  the 
face  grows  cyanotic,  the  spine  becomes  curved,  the  limbs  stretch- 
■ed),  but  after  a  few  seconds  the  tonic  spasms  give  place  to  clonic 


DISEASES    OF    Till-:    .\KR\OUS    SYSTEM  349- 

ones,  which  manifest  themselves  by  twitching  of  the  facial  muscles 
and  eye-balls,  froth  from  the  mouth,  shuddering  of  the  trunk  and 
extremities.  This  period  of  clonic  convulsions  lasts  considerably 
longer  than  the  first  one,  continuing  from  two  to  three  minutes 
up  to  half  an  hour  and  longer.  After  the  attack  the  child  usually 
falls  asleep  (soporous  period)  for  a  short  time. 

In  determining  the  cause  of  convulsions,  one  must,  first  of 
all,  decide  the  question  whether  they  depend  upon  coarse  anatomi- 
cal changes  in  the  central  nervous  system,  or  upon  some  other 
causes. 

Convulsions  may  be  met  with  in  chronic  and  acute  diseases  of 
the  brain.  In  the  diagnosis  of  cerebral  convulsions,  it  is  im- 
portant to  notice  the  fact  that  a  cerebral  disease  almost  never 
begins  with  an  eclamptic  fit,  so  that,  if  convulsions  appear  as  a 
symptom  of  some  cerebral  lesion  in  the  minute  examination  of 
the  patient  or  in  his  history  one  may  always  find  indications  of 
the  existence  of  some  brain  symptoms,  as,  for  instance,  in  chronic 
cases,  a  constant  or  often-repeated  headache,  pareses  of  the  mus- 
cles of  the  face  or  limbs,  some  mental  impairment,  changes  in 
the  eye-fundus,  etc. ;  and  in  acute  cases,  besides  these  symptoms 
there  may  also  be  somnolence,  fever,  irregular  and  retarded  pulse, 
etc. ;  therefore,  if  convulsions  occur  in  a  child  previously  entirely 
healthy,  who  after  the  end  of  the  paroxysm  does  not  exhibit  any 
other  cerebral  symptoms,  then  one  may  claim  with  great  prob- 
ability that  the  convulsions  zvere  not  cerebral. 

Convulsions  dependent  upon  chronic  lesion  of  the  brain  are 
also  characterized  by  being  very  liable  tO'  relapses,  reappearing 
after  various  intervals  of  from  a  few  days  up  to  several  weeks. 
It  is  true  that  such  repeated  convulsions  often  occur  in  children 
under  two  years  of  age  without  any  cerebral  disease,  but  the 
diagnosis  in  such  cases  is  aided  by  the  fact  that  of  chronic  cere- 
bral diseases  only  chronic  hydrocephalus  is  to  be  met  with  in  that 
age,  which  is  easily  recognizable  by  the  considerably  enlarged 
skull  and  divergency  of  the  sutures.  In  older  children  convul- 
sions repeated  during  months  and  even  years  depend  either  upon 
chronic  diseases  of  the  brain  (most  often  upon  a  tumor),  or  upon 
epilepsy. 

A  pure,  so  to  say,  idiopathic  epilepsy  usually  has  a  hereditary 
origin,   and  differs   from  a  symptomatic  epilepsy,  that   is,   men- 


350  DISEASES    OF    THE    NERVOUS    SYSTEM 

ingeal  convulsions,  by  its  extremely  chronic  course  and  by  the  fact 
that  the  child  does  not  exhibit  any  cerebral  symptoms  in  the  in- 
tervals between  the  convulsions.  (More  minutely  about  epilepsy 
see  below.) 

If  convulsions  constantly  affect  only  one  side  of  the  body,  this 
strongly  points  to  their  cerebral  origin,  and  the  more  so  if  the 
convulsions  spread  from  the  leg  to  the  arm  and  then  to  the  face, 
that  is,  according  to  the  order  of  localization  of  motor  centers 
in  the  central  convolutions  of  the  cerebral  cortex,  while  the  con- 
sciousness usually  remains  unimpaired.  These  symptoms  are 
those  of  the  so-called  cortical  or  Jacksonian  epilepsy. 

In  acute  cases  cerebral  convulsions  are  accompaned  by  fever, 
and  one  must  therefore  decide  the  question  whether  the  convul- 
sions depend  upon  meningitis  (or  upon  some  other  lesion  of  the 
brain),  or  simply  upon  elevation  of  the  temperature. 

Any  rapid  elevation  of  temperature  manifested  in  an  adult  by 
chill,  may  be  accompanied  in  small  children  by  convulsions,  and 
the  younger  the  child,  the  easier  they  set  in. 

These  so-called  febrile  convulsions,  or  eclampsia  due  to 
fever,  may  be  admitted  only  in  the  presence  of  three  conditions : — 

(i)  Age  of  the  child  under  three  years  (exceptions  are  very 
rare). 

(2)  Rapid  elevations  of  the  temperature,  not  less  than  about 
39.5  degrees  C.  (103.1  degrees  F.). 

(3)  The  convulsions  appear  during  the  first  hours  of  the 
affection,  that  is,  in  the  beginning  of  fever. 

It  follows  that  the  convulsions  most  probably  do  not  depend 
merely  upon  fever  if  one  of  these  conditions  be  absent,  when,  for 
instance,  the  child  is  older  than  three  years,  or  the  temperature  is 
low,  or  developed  slowly  (covering  two  or  three  days),  or  if 
the  convulsions  did  not  appear  during  the  first  day  of  the  disease. 

As  the  acute  cerebral  diseases  in  children  comparatively 
seldom  begin  with  a  sudden  and  severe  fever,  then  the  initial 
convulsions  in  such  connection  are  also  rare,  so  that  if  eclampsia 
appears  in  a  child  just  taken  sick,  the  temperature  being  40  de- 
grees C.  (104  degrees  F.),  then  it  is  very  probably  not  a  cerebral 
disease. 

It  is  true  that  some  forms  of  acute  purulent  meningitis  begin 
with  convulsions,  but  in  such  a  case  the  disease  runs  in  general 


DISEASES    OF    THE    NERVOUS    SYSTEM  351 

■very  rapidly,  the  patient  either  not  regaining  consciousness  alto- 
gether, or  the  convulsions  being  repeated  one  after  the  other, 
and  after  about  two  days  fatal  termination  sets  in.  Contrary  to  this, 
febrile  convulsions  usually  do  not  relapse  (a  violent  chill  in  adults 
also  is  not  repeated),  excluding  rare  cases  of  malignant  intermit- 
tent fever  (febris  intermittens  convulsiva).  and  the  patient  soon 
(after  ten  to  twenty  minutes)  recovers  his  senses*.  Thus,  if  con- 
vulsions appear  in  a  small  child  in  the  beginning  of  violent  fever, 
and  if  tlie  child  soon  recovers  Jiis  senses,  and  the  convulsioiis  are 
not  repeated  during  several  hours — then  acute  cerebral  diseases 
may  he  excluded,  leaving  it  yet  to  be  decided  upon  what  condi- 
tion the  fever  depends. 

But  besides  these  initial  convulsions  there  also  appears,  dur- 
ing some  febrile  diseases,  eclampsia  of  another  kind  in  which  we 
have  to  deal,  not  with  single  convulsions,  but  with  repeated  ones 
in  children  of  any  age,  and  not  alone  those  under  three  years. 

As  such  eclampsia  occurs  in  children  only  during  infectious 
diseases  and  especially  in  croupous  pneumonia  (almost  exclusively 
in  children  under  two  years),  scarlet  fever  and  small-pox  (in 
small  as  well  as  in  older  children),  and  at  the  same  time  always 
in  grave  cases,  then  one  may  in  such  instances  look  upon  the 
convulsions  as  not  so  much  depending  upon  the  elevated  tem- 
perature as  upon  the  poison  circulating  in  the  blood. 

If  the  convulsions  are  repeated  so  often  that  the  child  has 
no  time  to  recover  from  the  soporous  condition,  and  the  disease 
soon  ends  with  death  (in  scarlet  fever  sometimes  after  several 
hours  from  the  onset  of  the  disease),  then,  of  course,  the  similar- 
ity ^^•ith  grave  meningitis  (meningite  foudroyante)  may  be  so 
.great  that  the  diagnosis  cannot  be  made  on  the  ground  merely 
of  the  present  symptoms  and  in  the  absence  of  reasonably  definite 
signs  entirely  characteristic  of  this  or  that  disease,  as,  for  instance, 
rash  in  scarlet-fever  and  small-pox,  or  physical  signs  on  the  part 
of  the  lungs  in  pneumonia. 

*Sometimes,  although  seldom,  the  convulsions  appear  as  the  first  symp- 
toms of  tubercular  meningitis,  but  the  fever  is  in  this  disease  so  insignifi- 
cant (about  38  to  38.5  degrees  C.  or  100.4  to  101.3  degrees  F.),  that  con- 
vulsions, notwithstanding  their  occurring  once,  and  the  regaining  of  con- 
sciousness, cannot  be  explained  by  elevation  of  temperature,  so  that  for 
their  explanation  another  cause  must  be  looked  for.  In  the  great  ma- 
jority of  cases  convulsions  in  tubercular  meningitis  first  set  in  only  very 
■shortlv  before  the  fatal  termination. 


352  DISEASES    OF    THE    NERVOUS    SYSTEM 

Of  .eireat  importance  in  the  diagnosis  of  such  cases  is  the- 
aetiology,  therefore  it  is  necessary  to  inquire  if  the  patient  had 
been  exposed  to  the  infection  of  small-pox,  and  especially  scarlet- 
fever  (this  is  the  most  frequent  cause  of  fatal  cases  of  repeated 
convulsions  in  fever  even  in  more  adult  children),  if  he  did  not 
hurt  his  head,  if  he  was  not  overheated  by  the  sun,  if  he  had  not 
snuffles  or  cough  previous  to  the  severe  symptoms  (la  grippe 
as  a  cause  of  cerebral  pneumonia),  finally,  if  in  the  given  locality 
there  are  no  cases  of  epidemic  cerebro-spinal  meningitis. 

Not  infrequently  the  diagnosis  only  becomes  evident  several 
days  after  the  death  of  the  patient,  and  when  another  member  of 
the  family  becomes  ill  with  a  clearly  developed  infectious  disease, 
which  most  often  is,  of  course,  scarlet  fever. 

If  the  child  takes  suddenly  sick  with  violent  fever,  vomiting 
and  repeated  convulsions,  dying  after  twenty  to  thirty  hours 
with  symptoms  of  coma  and  collapse,  all  data  for  the  diagnosis 
being  absent,  then  the  physician  usually  regards  meningitis  as 
the  cause  of  death,  in  my  opinion  making  a  mistake  in  the  great 
majority  of  cases.  As  a  matter  of  fact  the  tubercular  form  of 
meningitis  never  occurs  in  such  a  manner;  a  simple  purulent 
meningitis  requires  for  its  development  some  certain  cause,  never 
arising  in  a  healthy  child  without  reason;  and  as  to  epidemic 
meningitis,  this  disease  in  general  occurs  very  seldom,  and  its 
hyper-acute  forms  almost  never,  so  that  in  cases  similar  to  the 
above  mentioned,  scarlet  fever  must  first  of  all  be  thought  of,  then^ 
small-pox,  and  at  last  meningitis. 

One  frequently  succeeds  in  recognizing  scarlet 'fever  in  the 
very  first  stage  of  the  disease,  because  the  rash  appears  very  early,, 
sometimes  during  the  first  hours,  and  if  the  rash  is  still  absent, 
then  the  scarlatinal  sore  throat  is  quite  certainly  present.  Small- 
pox is  of  more  difficult  recognition,  as  in  this  disease  the  mucous 
membrane  of  the  throat  is  not  involved,  the  rash  occurring  only 
on  the  third  day,  and  in  general  the  precursory  symptoms  are  but 
little  characteristic  unless  we  have  a  case  of  haemorrhagic  small- 
pox, in  which  peculiar  petechise  appear  on  the  abdomen  and  also 
on  other  parts  very  early,  for  instance,  on  the  first  or  second  day. 
Besides  this,  eclampsia  is,  in  small-pox,  of  considerable  severity, 
simulating  meningitis  by  the  repeated  convulsions.  These  are 
the   reasons    why,   practically,    eclampsia   in    small-pox   is    often 


DISEASES    OF    THE    NERVOl'S    SVSTE^[  353 

confused  with  meningitis.  As  an  important  aid  in  the  diagnosis 
the  character  of  epidemic  in  the  given  locahty  should  be  remem- 
bered, especially  if  the  patient  lives  in  a  small-pox  house;  also 
signs  of  vaccination  being  absent. 

We  shall  not  speak  here  about  the  distinction  of  meningitis 
from  the  so-called  cerebral  form  of  pneumonia,  the  reader  being 
referred  to  the  section  on  pneumonia.  However,  it  is  necessary 
to  mention  urccniia,  which  in  its  eclamptic  form  usually  develops 
in  children  with  considerable  elevation  of  temperature  (about 
40  degrees  C— 104  degrees  F.  and  higher).  If  the  convulsions 
be  often  repeated,  then  the  patient  does  not  come  out  of  a  coma- 
tous  condition,  and  the  similarity  to  acute  meningitis  is  then  the 
greater,  because  vomiting  necessarily  occurs.  Mistakes,  how- 
ever, do  not  often  happen,  as  it  is  not  easy  to  overlook  nephritis 
if  we  follow  the  rule  to  examine  the  urine  in  every  patient. 

Eclampsia  in  other  febrile  diseases  in  small  children  may  be 
difficult  for  the  physician  to  diagnose  for  a  few  hours  only,  as, 
first,  most  inflammatory  processes  soon  become  determinable,  and, 
second,  as  has  already  been  said,  these  convulsions  usually  are  not 
repeated. 

In  the  differential  diagnosis  of  cerebral  convulsions  from  a 
simple  febrile  eclampsia,  the  manner  of  development  or  the  group- 
ing of  the  cerebral  symptoms  are  important,  the  complexity  of 
which  may  be  such  that  it  can  be  explained  by  nothing  but  the 
cerebral  lesion.  Meningeal  expressions  dependent  upon  fever 
differ  from  genuine  cerebral  symptoms  by  the  insufficient  con- 
stancy and  by  their  not  increasing,  but  on  the  contrary  decreasing 
more  and  more  according  to  the  development  of  the  causative 
disease. 

As  to  the  convulsions  themselves  they  are  usually  preceded 
in  cerebral  diseases  by  a  very  violent  headache,  ivhich  is  intensive 
from  the  very  beginning  and  does  not  abate  until  there  is  finally 
loss  of  consciousness.  Real  cerebral  convulsions  in  acute  diseases 
of  the  brain  usually  occur  repeatedly,  leaving  then  a  deep  sopor- 
ous condition  in  which  the  patient  most  commonly  remains  until 
his  death. 

According  to  Barthez  and  Sarme,  cerebral  convulsions  differ 
from  a  common  eclampsia  by  the  following : — 

(i)  After  cerebral  convulsions  the  consequent  alterations  in 


354  DISEASES    OF     FHE    NERVOUS    SYSTEIM 

the  sphere  of  consciousness  and  motion  are  more  marked   (most 
often  there  occur,  for  instance,  paralyses  and  contractures). 

(2)  The  (hiration  of  the  attack  itself  is  longer. 

(3)  Cerebral  convulsions  are  very  prone  to  relapses;  if  in  a 
child  older  than  two  years  the  convulsions  be  repeated  in  succes- 
sion, then  they  are  almost  certainly  of  cerebral  origin  (we  have 
already  mentioned  that  similar  convulsions  in  older  children  may 
depend  upon  scarlet  fever  and  ursemia). 

In  estimating  cerebral  convulsions  one  may  also  be  guide^l 
to  some  degree  by  the  condition  of  the  large  foiitanelle,  while  at 
the  same  time  it  should  be  borne  in  mind  that  a  protruded  and 
pulsating  fontanelle  occurs  in  any  severe  febrile  condition.  Pro- 
trusion and  pulsation  of  the  large  fontanelle  may  be  held  as  un- 
doubted symptoms  of  hyperccniia  of  the  brain  only  if  both  are 
constant,  despite  the  fei'er  lo-wers,  while  simultaneously  somno- 
lency or  other  symptoms  of  the  brain-lesion  are  present. 

If  the  fontanelle  considerably  rises  over  the  parts  of  the  sur- 
rounding bones,  presenting  considerable  resistance  upon  pres- 
sure by  the  finger,  then  it  points  strongly  toward  the  existence 
of  an  exudative  process  in  the  brain,  as  in  febrile  diseases  the 
fontanelle  is  usually  easily  depressible,  although  it  may  pulsate 
and  become  protruded.  However,  a  contrar\-  conclusion  cannot 
be  made,  because  the  absence  of  increased  resistance  of  the  fon- 
tanelle does  not  exclude  the  existence  of  exudate  in  the  cavity  of 
the  skull. 

If  on  the  ground  of  these  or  other  considerations  cerebral 
diseases  may  be  excluded,  then  it  remains  to  determine  the  real 
cause  of  the  convulsions. 

The  causes  of  convulsions  in  children  are  extremely  mani- 
fold so  that  in  this  regard  four  kinds  of  eclampsia  are  to  be 
distinguished : — 

(i)  A  cerebral  or  symptomatic  one  (about  the  diagnosis  of 
this  form  we  have  already  spoken). 

(2)  Reflex  eclampsia,  dependent  upon  peripheral  irritation. 

(3)  Hsematogenous,  occurring  in  different  febrile  diseases 
and  poisonings,  and  finally, 

(4)  Idiopathic  or  essential  eclampsia,  the  causes  of  which 
are  unknown. 

According  to  the  advancement  of  our  knowledge  the  num- 


niSMASICS    OK    Till':    NKKX'OUS    SYSTEM  355 

ber  of  cases  included  in  the  latter  cate.Q;ory  will,  of  course,  de- 
crease. We  include  at  present  in  this  class  convulsions  due  to 
fright  and  otlier  psychical  conditions,  as  well  as  "groundless" 
convulsions  in  entirely  healthy  or  anaemic  children,  who  subse- 
quentlv  sometimes  suffer  from  epilepsy. 

For  the  ])urpose  t>f  diagnosis  all  cases  of  epilepsy  are  best 
divided  into  two  classes : — 

( 1 )  Convulsions  during  elevated  temperature  of  the  body, 
and 

(2)  Convulsions  without  fever. 

If  there  is  no  fever  in  the  child,  and  if  a  cerebral  disease 
may  be  excluded,  then  the  discovery  of  the  cause  of  convulsions 
may  be  influenced  by  the  patient's  age. 

Afebrile  convulsions  in  children  from  four  up  to  twelve 
years  old  occur,  in  general,  rarely ;  their  most  frequent  cause  is 
epilepsy.  General  convulsions  with  loss  of  consciousness  and 
consequent  short  somnolency  are  repeated  during  a  series  of  years 
at  different  intervals  of  from  several  weeks  up  to  whole  months. 
In  epilepsy  it  is  especially  characteristic  if  the  attacks  sometimes 
appear  at  night,  or  if  immediately  before  the  paroxysm  of  con- 
vulsions sets  in  the  patient  complains  of  this  or  that  sensation, 
known  as  aura. 

Aura  is  of  great  diagnostical  iyiportance,  because,  first,  it  is 
seldom  absent  in  elder  children,  and,  secondly,  because  in  the 
same  patient  it  always  recurs  quite  definitely.  '  Most  often  it  is 
described  by  the  patients  as  "a  blowing"  which  passes  from  the 
periphery  of  an  extremity  to  the  head,  in  other  cases  it  appears 
as  a  painful  sensation  or  as  "ringing  in  the  ears,"  flashes  before 
the  eyes,  or  an  odor  (aura  sensitiva)  ;  in  the  third  series  of  cases 
there  are  noted  the  so-called  abnormalities  in  the  motor  area, 
trembling,  twitching  (aura  motorica)  and  on  the  part  of  the 
psychical  condition,  for  instance,  hallucinations,  dizziness,  etc. 
Aura  usually  lasts  a  very  short  time  (a  few  seconds),  nevertheless 
it  enables  the  patient  to  assume  a  more  comfortable  position  and, 
so  to  say,  to  prepare  himself  for  the  attack. 

Of  the  fit  itself  there  is  complete  loss  of  consciousness  and 
the  absence  of  reflexes,  among  others  also  the  pupil-reflex,  the 
pupils  always  being  dilated. 

The  epileptic  fit  usually  lasts  about  two  or  three  minutes, 


356  DISEASES    OF    THE    NERVOUS    SYSTEM 

but  cases  of  epilepsy  occur  with  fits  of  much  shorter  duration  or 
even  entirely  without  definite  fits,  there  being  only  slight  twitch- 
ings  of  the  face.  Such  abortive  attacks  of  epilepsy  (petit  mal  s. 
epilepsia  minor)  are  manifested  thus : — The  child,  while  in  com- 
plete health,  suddenly  loses  consciousness,  grows  very  pale  and  in 
a  few  seconds  recovers  his  senses ;  the  loss  of  consciousness  is 
over  so  rapidly  that  the  patient  even  has  no  time  to  fall  down ; 
if  he  is  speaking  immediately  before  the  onset  of  the  attack  then 
he  stops  on  the  half-word  and,  the  interruption  ended,  he  then 
continues  talking.  During  the  attacks  the  patient  does  not  feel 
anything,  and  after  the  fit  does  not  remember  what  had  hap- 
pened to  him.  If  such  abortive  attacks  of  epilepsy  alternate  with 
convulsive  fits,  then  is  the  diagnosis  easy,  however,  if  real  epilep- 
tic attacks  are  absent,  then  the  case  may  be  properly  appreciated 
only  if  there  are  repeated  from  time  to  time  entirely  identical 
fits  of  loss  of  consciousness  of  several  seconds  duration. 

Similar  irregular  forms  of  epilepsy  make  themselves  evident 
sometimes  by  very  strange  fits.  For  instance,  I  knew  one  ten- 
year-old  boy  in  whom  the  epileptic  fits  appeared  in  the  form  of 
sudden  loss  of  consciousness,  the  patient  did  not  fall,  but  grasped 
the  first  object  under  his  hand  and  waved  it  in  the  air.  Once 
being  in  a  forest  near  a  wood-pile  he  seized  in  the  same  manner 
a  burning  piece  of  wood  and  caused  himself  a  severe  injury ;  upon 
another  occasion,  while  in  a  company  the  first  time  in  a  house 
he  during  a  lotto  play  grasped,  without  any  reason,  his  neigh- 
bor's head  and  soundly  pulled  him.  Reaching  fourteen  years  he 
became  free  from  such  fits. 

Irregular  varieties  of  epilepsy  in  the  form  of  the  so-called 
petit  mal,  like  the  actual  convulsive  fits,  may  be  a  manifestation 
of  some  chronic  cerebral  affection.  The  differential  diagnosis 
(Jackson's  epilepsy,  vide  supra),  is  partly  consequent  on  the 
condition  of  the  patient  during  the  intervals.  In  favor  of  cere- 
bral lesion  are  different  mono-  and  hemiplegias,  h^emianassthesia, 
persistent  headaches  especially  with  vomiting.  All  these  symp- 
toms are  to  be  readily  observed.  It  is  more  important  perhaps  to 
point  out  that  sometimes,  simultaneously  with  the  fits  of  petit 
mal  in  the  form  of  short  dizziness  or  slight  twitching  of  the  facial 
muscles,  there  is  found  for  a  long  time  (a  few  months)  out  of  all 
cerebral  symptoms  only  a  slight  paresis  of  the  facial  nerve,  notice- 


DISEASES    OK    THE    NERVOUS    SYSTEM  357 

able,  for  instance,  at  the  sli()\vin<;-  of  the  teeth,  or  there  arc  changes 
in  the  eye  fundus  in  the  form  of  oedematous  papilla.  Both  these 
signs  must  always  be  especially  taken  into  consideration,  before 
the  physician  limits  himself  to  the  diagnosis  of  an  idiopathic  strand 
or  petit  mal  (great  or  small  epilepsy). 

In  childhood  one  seldom  has  to  deal  with  a  feigned  epilepsy, 
which  dilTers  from  a  real  one  among  other  symptoms  by  the  fact 
that  the  patient  when  falling  in  convulsions  never  hurts  himself 
and  does  not  bite  his  tongue,  as  well  as  by  the  reflexes  in  a 
dissembler  being  always  preserved  (he  shudders  upon  the  sud- 
den sprinkling  of  his  face  with  cold  water,  and  his  pupils  react 
excellently  to  light). 

Great  similarity  to  epilepsy  may  be  presented  by  some  cases 
of  hysterical  convulsions,  known  under  the  name  of  hystero- 
epilcpsy.  The  paroxysm  of  the  latter  differs  from  epilepsy  by  the 
incomplete  loss  of  consciousness  and  by  the  epileptic  fit  beginning 
usually  with  screaming,  often  being  accompanied  by  biting  of  the 
tongue,  incontinence  of  the  urine  and  faeces  as  well  as  by  sopor, 
and  when  the  attack  is  over  the  patient  does  not  remember  what 
happened ;  while  in  hysterical  convulsions,  biting  of  ^^^e  tongue, 
screaming,  involuntary  urination,  as  well  as  complete  anaesthesia 
are  usually  absent.  Further,  one  must  pay  attention  to  heredity 
and  ascertain  if  the  patient  does  not  represent  some  of  the  char- 
acteristics of  hysteria,  known  as  hysterical  labels  or  stigmata, 
which  most  often  occur  in  the  sphere  of  the  organs  of  sense,  as, 
for  instance,  different  hyperccstliesicc  and  ancesthcsicc.  [In  in- 
fantile hysteria  the  stigmata  peculiar  to  the  aft"ection  in  adults 
are  mostly  absent,  being  usually  of  iiioiiosyiiiptoiiiatic  character 
(i.  e.,  in  the  clinical  expression  one  symptom  prevails,  as  paralysis, 
mutism,  tic,  vomiting,  etc.,  a  combination  of  symptoms  being  pos- 
sible,   but    I'ery    iiiicoiiiinoii). — Thiemish,'^'      Bruns.** — Earle.] 

Hyperaesthesia  of  the  skin  shows  itself  by  a  considerable  pain- 
fulness  upon  pressure  over  some  areas  of  the  body,  especially  over 
the  spinal  processes  and  abdomen,  as  well  as  by  different  neural- 
gia and   frequent   headaches.      Hyperssthesise   of   other   organs 


*Thieniish    (Ueber   Hysteric    im   Kiiidcsalter — JaJirb.     f.     Kinderhcilk. 
LVIII.,  6,  1903). 

**Bruns   (Ibidem). 


358  DISEASES    OF    THE    NERVOUS    SYSTEM 

of  sense  manifest  themselves  by  ringing  in  the  ears,  flashes  before 
the  eyes  and  pecuHarities  of  the  senses  of  smell  and  taste. 

Still  more  significant  are  different  anaesthesise  which  usually 
do  not  correspond  altogether  to  the  distribution  of  the  nerves, 
especially  notable  are  hemianassthesige  and  anaesthesise  in  the 
form  of  cufifs  (the  hands  and  the  lower  end  of  the  forearm  of 
one  or  both  sides),  it  is  also  peculiar  if  over  a  vast  area  of  com- 
plete loss  of  sensibility  there  suddenly  appears  a  small  islet  of 
skin  entirely  sensitive. 

Anaesthesia  mav  be  either  complete,  or  affect  only  some  forms 
of  irritation,  for  instance,  the  patient  does  not  feel  pricks,  but  is 
sensible  of  a  slight  touch,  etc. 

On  the  part  of  special  organs  of  sense  concentric  limitaticMis 
of  the  field  of  vision  in  one  eye  occurs  comparatively  often,  or, 
more  often,  in  both  e}es ;  there  also  occurs  in  hysteria  loss  of 
sensibility  of  the  soft  palate  and,  generally,  of  the  pharynx. 

It  is  furthermore  important  to  note  in  hysteria  iuipainncnt 
of  the  psychical  condition,  there  being  some  reason  why  hysteria 
is  at  present  held  to  be  a  mental  disease.  The  patients  are  very 
irritable,  snivelling,  capricious  and  are  distinguished  by  rapid 
changes  in  their  s])irits,  either  an  unreasonable  sadness,  or  an 
equally  causeless  exaltation.  I  lysterical  patients  easily  fall  into 
hy])n()tic  sleep  and  obey  suggestions,  fre(|ucntly  evcii  while  in  the 
condition  of  vigilance. 

All  these  circumstances  should  be  given  attention  as  soon 
as  there  arises  any  suspicion  of  the  hysterical  nature  of  any 
symptoms  and  in  the  given  case  of  general  convulsions.  Un- 
fortunately, all  these  stigmata  occur  in  childhood  with  less  fre- 
quency than  in  adults,  therefore  the  diagnosis  of  h_\steria  in  chil- 
dren mav  sometimes  present  great  difficulties. 

Of  special  value  in  the  diagnosis  of  convulsions  are  two 
more  circumstances;  first,  the  results  of  bromide  treatment.  This 
remedy  does  not  noticeably  influence  hysterical  convulsions, 
while  epileptic  fits  generally  decrease  quite  rapidly  and  become 
less  frequent.  Secondly,  the  properties  of  the  urine,  which  as 
a  matter  of  fact,  are  sharply  changed  after  an  attack  of  hysterical 
convulsions ;  the  quantity  of  solids  decreases  by  one-third  ( nor- 
mally forty  or  fifty  grams  in  twenty-four  hours,  and  after  the 
attack  thirty  or  thirty-five).     This  diminution  ]M-incipally  aft'ects 


DISEASES    OF     THE    NEKN'OUS    SYSTEM  359 

the  urea  and  the  ])hi)S])hates.  IJesides  this  there  are  striking; 
chanij;-es  in  the  ratio  of  the  {jhosphate-Hine  sahs  to  the  alkalies; 
normallx  the  former  are  approximately  one-third  less  than  the 
latter  (1:3),  hut  after  an  hysterical  attack  the  ratio  is  as  i  ;i, 
while  after  epileptic  convulsions  nothing  similar  occurs,  on  the 
contrar\-  the  amount  of  urea  and  phosphates  increases. 

As  to  the  diagnosis  of  convulsions  dtte  to  unnemia  one  should 
remeiuber  that  after  a  real  epileptic  attack  albumin  and  hxaline 
casts  appear  in  the  urine,  but  both  are  observed  not  longer  than 
twenty-fottr  or  forty-eight  hours. 

Tf  the  patient  never  had  convulsions  previously,  and  any  data 
regarding  epilepsy  or  other  serious  nervous  diseases  are  absent  in 
his  history,  then  one  shotild  think  either  of  ttnemia  (examination 
of  the  urine,  (edemata),  or  of  poisoning,  among  other  substances, 
with  santonin  and  alcohol   (history). 

In  small  children  (under  five  years)  the  cause  of  convulsions 
may  be  a  foul-stomach  or  intestinal  worms  (examination  of  the 
dejections  for  eggs  and  elimination  of  the  worms,  viz.  their 
segments).  As  a  rare,  but  undoubtedly  possible,  cause  of  con- 
vulsions, one  may  detect  a  foreign  body  in  the  ear,  whether  this 
be  a  large  old  cerumen,  or  something  else. 

From  eclampsia  epilepsy  differs  not  by  the  cliaracter  of  the 
fits,  as  these  are  the  same  in  both  cases,  but  by  the  fact  that 
eclampsia  is  an  acute  disease,  and  epilepsy  a  chronic  one.  It  is 
obvious  that  if  the  ])hysician  has  to  deal  with  the  first  fit.  then 
he  cannot  know  if  it  will  be  repeated,  so  that  the  diagnosis  is  in 
such  case  impossible.  Nevertheless,  as  epilepsy  in  children  usual- 
ly begins  as  petit  iiial.  and  liant  nial  appears  nmch  later,  after  a 
whole  series  of  small  attacks,  then  one  may  suppose  with  some 
probability  that  he  has  not  to  do  with  e])ilepsy  as  soon  the  first 
attack  of  general  convulsions  appears  in  a  child  previousl\-  never 
suffering  from   "swoons." 

/;;  children  from  six  iiiuiiths  up  to  t'wo  and  a-half  years  of 
ai!;e  afebrile  convulsions  occtu'  most  t)ften  in  those  stififeriug  with 
rachitis  and  especially  during  laryngismus  stridulus.  L'pon  ex- 
amination of  such  a  child  it  is  easy  to  note  rachitic  changes  in  the 
skull-bones  (in  children  under  one  year  of  age  there  is  always 
softening  of  the  occiput)  and  the  chest,  and  in  the  histor\-  at- 
tacks of   larvngo-s])asm.     These   fits,   characterized  1)>-   whistling 


360  DISEASES    OF    THE    NERVOUS    SYSTEM 

inspiration,  appear  especially  often  (several  times  a  day)  in  a 
child  during  crying,  but  in  the  great  majority  of  cases  they  stop 
so  rapidly  that  they  do  not  do  any  harm  to  the  patient.  But 
some  of  them  are  so  severe  that  the  child  cannot  breathe,  general 
convulsions  commencing  soon  after  this  apnoea.  From  any  other 
convulsions  the  former  differs  by  the  beginning  or  the  end  of 
the  fit  being  marked  by  a  whistling  inspiration. 

Eclampsia  sometimes  occurs  in  rachitic  children  even  with- 
out laryngismus  stridulus,  because  of  the  considerable  irritability 
of  their  nervous  system  under  the  influence  of  an  abnormal  con- 
dition of  the  general  nutrition. 

It  rarely  occurs  that  convulsions  affect  other  than  rachitic 
children,  in  such  cases  the  irritability  of  the  nervous  system 
develops  either  on  the  ground  of  anicmia,  or  under  the  influence 
of  heredity. 

This  latter  case  manifests  itself  in  almost  all  children  of  the 
given  family  suffering  at  a  certain  age  (in  the  first  or  second 
year)  from  convulsions.  Such  a  curious  case  of  ''a  family  eclamp- 
sia" is  given  by  Bouchut :  in  one  family  there  were  ten  children 
and  all  of  them  suft'ered  during  their  first  year  from  convulsions ; 
one  of  the  girls  married  in  due  time  and  also  brought  forth  ten 
children,  in  nine  of  whom  there  was  eclampsia. 

Thus,  the  chief  cause  of  convulsions  in  small  children  is  a 
peculiar  condition  of  their  central  nervous  system  under  the  in- 
fluence of  rachitis,  more  rarely  anaemia  or  hereditary  predisposi- 
tion. 

The  disposition  to  convulsions  may  be  so  great  that  eclamptic 
fits  sometimes  appear  without  any  noticeable  accidental  factors,  or 
under  the  influence  of  the  most  insignificant  causes  ;  in  a  child 
with  a  disposition  to  laryngismus  stridulus  convulsions  are  not 
infrequently  caused  by  the  slightest  psychical  excitement,  the  fits 
being  repeated  during  each  loud  cry,  etc.  In  such  condition 
about  ten  or  twenty  convulsive  seizures  a  day  may  be  observed  in 
a  child.  One  may,  in  general,  say  that  if  in  a  child  a  few  months 
old  and  seemingly,  at  first  glance,  healthy,  the  convulsions  are 
repeated  every  day  and  even  several  times  a  day,  then  a  minute 
examination  will  almost  always  show  that  such  a  child  is  a  rachi- 
tic one,  suft'ering,  perhaps,  at  the  same  time  with  laryngismus 
stridulus  and  also  with  a  softened  occiput. 


DISEASES    OF    THE    NERVOUS    SYSTEM  361 

In  Other  cases  convulsions  appear  onl}'  under  the  inllucncc:  of 
■some  definite  cause,  wliich  is  most  often  fever  and  foul-stomach, 
•especially  constipation.  It  is  also  undoubtedly  true  that  the  oc- 
casional cause  of  convulsions  may  be  some  psychical  excitement 
(fright)  and  irritation  of  the  peripheral  nerves,  for  instance, 
during  dentition.  Eclampsia  dependent  upon  the  latter  differs 
from  any  other  eclampsia  only  by  convulsive  fits  appearing  in  the 
x:hild  at  each  new  dentition  (see  page  lOo). 

In  children  of  the  first  months  of  life  convulsions  may  be 
the  consequence  of  colics  (dyspeptic  stools,  expanded  abdomen, 
continuous  cry)   or  of  constipation  or  some  diet  errors. 

To  the  last  class  Henoch  (page  159)  refers,  for  instance, 
•cases  of  eclampsia  in  nurslings  after  they  had  taken  the  breast 
of  a  violently  excited  wet-nurse.  In  the  same  category  may  be 
included  eclami^sia  in  children  after  they  have  taken  indigestible 
food ;  in  one  of  my  cases  convulsions  in  a  sick  child  were  pro- 
duced, for  instance,  by  a  few  tablespoonfuls  of  sour-cabbage 
soup,  in  another  one,  by  a  teaspoonful  of  whiskey.  Cases  described 
^by  Henoch  prove  that  the  same  causes  may  produce  convulsions 
in  children  two  to  three,  and  even  six  years  old. 

For  the  correct  estimation  of  such  cases  it  is  important  to 
•detect  a  gross  error  in  the  diet,  or  constipation,  in  the  days  pre- 
ceding the  convulsions.  Not  infrequently  the  spasms  are  pre- 
ceded by  vomiting  and  fever,  if  constipation  be  followed  by  a 
diarrhoea  (occurring,  so  to  say,  voluntarily  or  after  a  laxative), 
•then  this  is  usually  marked  by  very  foetid  dejections. 

Regarding  children  of  the  first  months  of  life  it  should  be 
mentioned  that  the  cause  of  convulsions  in  them  may  be  a  tiiii- 
■dered  urination  due  to  severe  phimosis  or  urinary  calculi;  in 
the  last  case  the  child  cries  violently  before  the  micturition,  be- 
•coming  quiet  after  emptying  the  bladder. 

Finally,  afebrile  eclampsia  in  nurslings  may  be  the  result 
•of  passive  hyperasmia  of  the  brain  for  instance,  in  whooping- 
•cough  or  in  oedema,  and  in  anaemia  during  infantile  cholera. 

About  febrile  convulsions  we  have  already  spoken. 

Convulsions  characteristic  of  eclampsia  and  occurring  in  at- 
tacks of  short  duration  but  with  loss  of  consciousness,  have  no 
resemblance  to  those  almost  continuous,  involuntary  movements 
which   appear  in   the  presence   of  complete   consciousness   char- 


362  niSEASES    OF    THE    NERVOUS    SYSTEM 

acterizing  St.  Vitus'  dance — chorea.  Chorea  occurs  in  differ-- 
ent  forms,  as,  for  instance,  symptomatic,  hereditary  and  hysterical 
chorea,  but  all  the^e  forms  will  be  mentioned  later  on ;  here  we 
will  occui)v  ourselves  only  with  idiopathic  chorea,  known  also 
under  the  name  of  infantile,  or  Sydenham's,  chorea. 

In  this  malady  real  convulsions  are  absent,  only  motor  dis- 
orders of  co-ordination  being"  manifested  by  the  muscles  not 
entirely  obeying  the  will ;  the  voluntary  movements  are  mixed 
with  involuntary  muscular  contractions,  peculiar  of  chorea  and 
characterized  by  the  facts  ( i )  that  they  cease  during  sleep,  and 
(2)  thev  increase  upon  the  psychical  excitement  of  the  patient 
and  his  effort  to  perform  a  voluntary  movement. 

Once  started  chorea  usually  lasts  a  few  weeks  or  months 
(the  average  being  about  three  months).  In  the  mildest  cases  the 
whole  disease  is  shown  by  the  restlessness  of  the  muscles ;  the 
patient  camiot  remain  a  long  time  in  a  c|uiet  condition;  either  his 
lingers  will  bend  and  extend  again,  or  the  shoulder  will  rise, 
or  a  grimace  will  appear  on  the  face.  etc. 

It  is  esi)ecially  easy  to  note  the  abnormalit\-  of  movements 
if  the  i^atient  be  compelled  to  ])erform  some  definite  muscular 
act,  for  instance,  to  extend  the  arm,  to  button  up  a  garment, 
etc. 

In  mild  cases  the  restlessness  of  the  muscles  appears  con- 
stantly, also  increasing  upon  voluntary  acts.  In  many  cases  the- 
eve-lids  and  the  tongue  are  most  involuntary  in  character,  this 
being  recognized  by  the  i:)atient  being  unable  to  long  keep  his 
tongue  protruded  or  to  firmly  shut  his  eyes.  These  particular 
features  may  be  used  in  judging  whether  the  disease  is  improving 
or  not :  we  make  the  patient  protrude  his  tongue  and  so  hold  it 
until  we  count  ten;  in  severe  cases  the  tongue  recedes  into  the 
mouth  after  two  or  three  seconds,  and  after  five,  eight  or  ten 
seconds  when  undergoing  im])rovement.  The  same  with  the 
eye-lids ;  the  patient  can  keep  his  eye-lids  well  compressed  only 
one  to  three  seconds,  and  longer  with  the  improvement  of  the- 
disease. 

In  grave  cases  involuntary  movements  hindei  the  voluntary 
ones  to  such  an  extent  that  complete  disorder  of  co-ordination 
appears,  so  that  the  patient  cannot,  for  instance,  carry  a  spoon 
to  the  mouth,  cannot  cross  himself,  etc.,  and  must  lie  in  a  bed 


DISEASES  oi--    nil-.   XEinors  s^'s■l•|•:^[  365 

surrouiuled  with  piuldcd  walls,  as  1  )llKTwisc  under  llic  iuHuciicc 
of  continuous  uio\cnicnts  ])r()(luced  by  the  trunk,  as  well  as  b\-  the 
extremities,  he  would  certainly  fall  to  the  floor. 

Ill  the  most  severe  cases  chorea  continues  even  at  night  and 
entirely  deprives  the  patient  of  sleep,  so  that  he  becomes  weak 
to  such  a  degree  that  his  condition  is  dangerous.  With  the  ap- 
proach of  death  there  is  sometimes  observed,  besides  collapse, 
fever  and  delirium,  ending  with  complete  coma.  Fortunately 
such  cases  belong  to  the  great  rarities. 

Among  the  constant  symptoms  of  chorea  which  are  met  with 
even  in  comparatively  mild  cases  may  also  be  included  mental 
derangement  and  change  in  the  character  :  the  patient  loses  his 
memory  (it  is,  for  instance,  more  difficult  for  him  to  commit 
something  to  memory),  is  not  attentive  enough,  being  therefore 
punished  in  school  he  becomes  irritable,  whining ;  on  the  con- 
trary the  sensibility  remains  normal,  only  hyperaesthesia  being 
sometimes  noticed  upon  pressure  over  the  spinous  processes  of 
some  dorsal  vertebra?.  The  bladder  and  rectum  are  not  affected  in 
chorea ;  but  the  same  cannot  be  said  about  the  heart. 

Under  the  name  of  chorea  of  the  heart  diverse  irregularities 
of  the  cardiac  activity  are  described,  occurring  during  chorea  and 
disappearing  with  the  recovery  therefrom ;  here  are  included  ir- 
regularities of  the  pulse  without  any  subjective  symptoms,  or 
tachyacardia  manifested  sometimes  by  marked  cjuickening  of  the 
pulse  after  some  slight  movements  as,  for  instance,  a  few  steps 
in  the  room  are  sufficient  to  raise  the  frequency  of  the  pulse  from 
90  up  to  120  or  130.  In  other  cases  there  are  found  inorganic, 
slight  systolic  murmurs  of  blowing  character  at  the  apex  of  the 
heart ;  from  the  organic  murmurs,  which  are  quite  frequent  in 
chorea,  these  dynamic  murmurs  ( aUcTmic  murmurs,  or  dependent 
upon  the  irregular  innervation  of  the  musculature  of  the  heart  j 
are  distinguished  by  their  changeableness  (one  day  they  are 
stronger,  the  next  weaker),  and  further  by  their  disappearing 
after  the  chorea  is  cured. 

Chorea  begins  either  at  once  quite  violently,  or  disorder  of 
co-ordination  first  appears  in  mild  degree  and  especially  unilater- 
ally, then  gradually  increasing  for  two  or  four  weeks,  remains 
at  the  maximum  plane  one  to  two  months  and  then  gradually 
decreases,  while  recovery  commonly  follows  after  three  months. 


364  DISEASES    OF    THE    NERVOUS    SYSTEM 

A  patient  having  been  sick  with  chorea  remains  for  a  long 
time  disposed  to  a  recurrence  of  this  disease,  which  may  be 
repeated  every  year  for  two,  three  and  more  years  in  succes- 
sion. 

Idiopathic  chorea  very  seldom  occurs  in  strong  and  seemingly 
healthy  children  under  the  influence  of  some  accidental  causes, 
for  instance,  fright,  but  usually  develops  because  of  ansemia  and 
hereditary  nervousness  or  under  the  influence  of  rheumatism ;  in 
the  latter  case  it  is  altogether  unnecessary  that  there  should  be 
an  endocarditis.  Chorea  may  be  produced  by  an  acute  articular, 
as  well  as  by  a  muscular  form  of  rheumatism,  for  instance,  torti- 
collis. Rheumatic  chorea  differs  from  any  other  form  only  by 
being  j^receded  or  followed  by  rheumatic  pains.  Much  less  often 
than  after  rheumatism,  chorea  follows  some  other  infectious 
diseases,  most  important  of  which  is  scarlet  fever. 

[L.  Harrison  Mettler  has  presented  elaborate  proofs  that 
chorea  may  also  be  produced,  although  not  very  often,  by  syphilis, 
which  "should  always  be  thought  of  as  a  possibility  in  the  ex- 
amination of  every  case" ;  that  acquired  as  well  as  hereditary 
syphilis  may  cause  chorea ;  that  most  of  the  cases  of  syphilitic 
chorea  are  unilateral,  belonging  to  the  prchemiplegic  or  posthemi- 
plegic t}pe  of  the  disease ;  that  they  may  or  ma}-  not  be  asso- 
ciated with  other  signs  of  an  irritative  lesion ;  that  they  are  not 
infrequently  developed  in  hereditary  syphilitics,  and  are  to  be 
attributed  probably  to  a  functional  disturbance  of  an  irritative 
sort  in  the  cortical  and  ganglionic  motor  cells.'''  Preobrazhensky 
is  of  the  opinion  that  chorea  minor  is  due  to  a  streptococcus  in- 
fection, as  he  was  able  to  find  streptococci  in  the  blood  of  a 
patient  who  suft'ered  from  a  severe  chorea  and  which  was  success- 
fully cured  by  him  with  antistreptococcus  serum,  while  all  other 
methods  of  treatment,  as  arsenic,  chloral  hydrate  and  bromides 
failed**.  Of  the  same  opinion  is  Reichhardt  who  found  staphy- 
lococci in  the  blood  in  one  post  mortem  of  a  choreic  patient***. — 
EarlE.  ] 

As   to   the   relation   between   chorea   and   cardiac    lesions   it 


*L.  Harrison  Mettler:  Syphilis  as  a  Cause  of  Chorea.  Amer.  Journ. 
Med.  Sci.,  September,  1903,  p.  487. 

**Medic.  Obosren.  (Abstract  in  Jour.  Am.  Med.  Assn.,  Aug.  29,  1903, 
p.  587). 

***Dcut.  Arch.  f.  Klin.  Med.,  Vol.  LXXIL,  Nos.  5  and  6. 


DISEASES    OF    TIIK    NERVOUS    SYSTEM  365 

may  be  said  that,  although  the  latter  occur  in  chorea  quite  often, 
nevertheless  one  should  bear  in  mind  that  not  every  murmur 
in  the  cardiac  region  proves  the  existence  of  a  valvular  defect; 
and  that  the  so-called  dynamic  cardiac  murmurs  occur  in  choreas, 
perhaps,  still  oftener  than  the  organic  ones. 

The  diagnosis  of  idiopathic  chorea  is  not  difificult ;  peculiar 
twitchings  and  involuntary  movements,  distinctive  of  this  malady, 
are  so  typical  that  if  once  seen  they  may  always  be  recognized. 

From  symptomatic  chorea,  as  a  symptom  of  a  chronic  affec- 
tion of  the  brain,  Sydenham's  chorea  differs  by  the  former  belong- 
ing to  chronic  or  incurable  diseases,  accompanied  by  some  other 
cerebral  symptoms,  as  in  some  cases  persistent  headache,  paralyses 
(especially  of  the  eye-muscles)  and  mental  derangement,  in  other 
cases — spastic  mono-  or  hemi-diplegia  and  slow  development  of 
the  paralyzed  extremities.  Symptomatic  chorea  most  often  oc- 
curs in  cerebral  paralyses  of  inherited  origin,  therefore  appear- 
ances of  chorea  (chorea  post-paralytica)  are  dated,  usually,  from 
the  first  months  of  life. 

[Mettler,  in  view  of  his  observations  and  studies  comes  to 
the  conclusion  that  chorea  (minor)  is  not  a  disease,  but  a  mere 
symptom  dependent  upon  a  variety  of  possible  causes.  "All 
choreas,"  says  he,  "are  symptomatic — symptoms  of  a  more  or 
less  distinctive,  or  at  least  disturbing,  toxjemia."* — Earle.] 

Hereditary  or  Huntington's  chorea  is  characterized  by  being 
transmitted  hereditarily,  is  not  manifested  in  childhood,  but  only 
after  thirty  or  forty  years,  and  lasts  for  years  until  death  oc- 
curs. 

As  to  hysterical  chorea^  this  is  of  two  kinds ;  in  some  cases 
an  ordinary  chorea  appears  in  an  hysterical  person,  in  others  we 
have  to  deal  with  a  peculiar  manifestation  of  chorea.  The  former 
cases  differ  from  a  common  chorea  by  the  patient  manifesting 
besides  chorea  other  symptoms  of  hysteria  (haemiangesthesia,  ec- 
centricity of  the  character,  etc.),  and  a  real  chorea  hysterica  is 
further  characterized  by  the  movements  being  rhythmical,  repeated 
always  in  the  same  manner. 

Under  the  head  of  chorea  clectrica  two  entirely  dififerc" 


*Mett]er:   Neurological  Clinic,  Clinical  Review,  January,   1904,  p.  263. 
.See  also  Amer.  Jour.  Med.  Set.,  September,  1903,  p.  241. 


366  DISEASES    OF    THE    NERVOUS    SYSTEM 

diseases  are  described ;  chorea  electrica  of  Dnbini  and  chorea 
electrica  of  Bergeron. 

The  former  seems  to  occur  only  in  Italy ;  it  is  characterized 
by  rhythmical  twitchings  of  the  muscles  of  the  extremities  and 
face ;  lasts  an  indefinite  time ;  leads  to  paralyses  and  ends  with 
death  in  the  condition  of  coma. 

On  the  contrary  Bergeron's^  disease  is  of  benign  course  and 
usually  ends  with  recovery,  although  sometimes  it  becomes  pro- 
tracted for  about  two  years  and  even  more.  It  is  indicated  by 
the  appearance,  after  more  or  less  short  intervals  of  time,  of  very 
rapid  twitching  always  of  the  same  muscles,  or  group  of  mus- 
cles. Most  often  there  are  movements  of  the  head  (backwards, 
forwards  or  to  the  side)  and  of  the  upper  extremities.  If  the 
twitchings  appear  in  the  region  of  the  facial  nerve  then  we  have 
the  picture  of  a  common  tic  convulsif,  the  main  difference  being 
the  incurability  of  the  latter.  As  a  peculiarity  of  Bergeron's 
disease  by  which  it  differs  from  other  similar  morbid  forms  the 
French  authors  point  out  the  beneficial  effect  of  vomiting-doses 
of  tartar  emetic.  After  taking,  every  other  day,  two  doses  (0.05, 
or  I  grain,  at  a  dose)  of  tartar  emetic  the  twitchings  seem  to 
disappear  immediately.  As  chorea  electrica  almost  always  occurs 
in  hysterical  persons,  then  it  is  very  probable  that  such  a  strong 
remedy  acts  by  way  of  auto-suggestion.  The  value  of  this  remedy 
is,  however,  exaggerated,  and  no  diagnosis  can  be  made  on  the 
basis  of  the  therapeutic  results  observed  therewith.  In  Cadet  de 
Gassicourt's  case,  for  instance,  this  remedy  proved  useless,  and 
recovery  came  on  after  faradic  electrization. 

Some  resemblance  to  chorea,  that  is  to  its  initial  period,  may 
be  represented  by  local  clonic  convulsions,  for  instance,  by  tic 
CONVULSIF  and  twitching  of  the  muscles  of  the  face  (involuntary 
grimaces)  or  of  other  muscles,  especially  those  of  the  neck,  so 
that  the  child  performs  peculiar  movements  with  the  head,  mani- 
fested the  clearer  the  more  the  child's  attention  is  occupied  (as 
during  writing,  solving  of  arithmetical  problems,  etc.).  If  such 
local  spasms  of  the  muscles  are  the  expression  of  a  beginning 
chorea,  then  in  a  short  time,  viz.,  in  about  two  weeks,  the  dis- 
orders of  co-ordination  will  also  appear  in  other  portions  of  the 
body  and  especially  in  the  arms ;  if,  however,  the  local   spasm 


DISEASES    OF    THE    NEKVOUS    SYSTEM 


Z^^7 


\ 


/fi 


i 


^^- 


Fig.  2)^ — Position  of  hands  in  the  spasm  of  tetanj'    (Oppenhein»). 


368  DISEASES    OF    THE    NERVOUS    SYSTEM 

occurs  as  an  independent  lesion,  then  it  remains  stationary  for 
many  weeks  and  even  months. 

To  the  same  class  of  local  clonic  convulsions  belongs  also 
the  so-called  spasmus  nutans,  consisting  in  that  the  child  con- 
stantly performs  nodding  movements  with  the  head  (bends  and 
extends  the  head),  or  with  the  whole  trunk.  This  disease  usually 
continues  a  few  weeks,  frequently  being  combined  with  strabismus 
and  nystagmus  (trembling  of  the  eye-balls)  and  then  is  over, 
unless  it  depends  upon  some  central  lesion.  According  to  Henoch, 
spasmus  nutans  often  disappears  soon  after  the  appearance  of  a 
new  tooth. 

There  should  also  be  mentioned  at  this  point  a  constant,  in- 
vohmtary  movement  of  the  fingers,  known  under  the  name  of 
athetosis.  These  movements  usually  do  not  stop  even  during 
sleep.  This  affection  has  an  extremely  chronic  course  lasting 
many  years ;  it  is  usually  combined  with  pareses,  or  with  some 
other  symptoms  which  show  the  cause  of  athetosis  to  be  a  central 
one,  localized,  perhaps,  in  the  cerebral  cortex. 

Tetany  (Tetania).  The  chief  symptom  of  typical  cases 
of  tetania  appears  in  the  symmetrical  contraction  of  the  hands 
and  fingers,  sometimes  of  the  feet,  consciousness  being  non-im- 
paired, and  with  no  other  symptoms  which  would  denote  some 
gross  material  changes  in  the  central  nervous  system. 

This  malady  is  shown  by  the  peculiar  form  of  the  contracted 
parts;  the  hand  is  flexed  at  the  wrist-joint,  the  thumb  bent  into 
the  palm  of  the  hand,  and  the  four  fingers,  remaining  extended 
in  the  interphalangeal  joints,  are  flexed  in  the  metacarpo-phalan- 
geal  ones,  while  the  little  finger  and  the  index  approximate  each 
other,  being  located  with  their  ends  over  the  ring  and  the  mid- 
dle fingers,  so  that  the  whole  wrist  assumes  a  form  very  similar 
to  that  of  the  accoucheur's  hand  when  about  to  introduce  the 
same  into  the  vagina  (Trousseau).  (Fig.  36.)  The  toes  also  are 
flexed  only  in  the  metatarso-phalangeal  articulations  or  remain 
extended  and  spread,  so  that  the  foot  assumes  the  form  as  in  pes 
equinus. 

In  nearly  one-half  of  all  cases  only  the  arms  become  in- 
volved, the  legs  remaining  unaffected.  Comparatively  seldom  the- 
spasm  spreads  to  the  forearm  (flexion  of  the  arms  at  the  elbow- 
joints'!    and  to  ochef   above-attached  muscles    (adductors  of  the- 


DISEASES    OF    THE    XKRVOUS    SYSTEM  369 

shoulders)  ;  in  nursliiii^s  the  llexion  spreads  sonictinies  to  the 
occiput,  back  and  abdominal  muscles  and  pectoralis  major. 

A  forcible  extension  of  the  contracted  fingers  causes  the 
child  pain  and, necessarily  makes  him  cry.  The  contracture  after 
once  appearing"  lasts  a  long  time,  from  a  few  hours  up  to  several 
days,  without  interruption,  even  during  sleep.  The  conscious- 
ness in  tetany  is  not  impaired ;  the  sensibility  of  the  skin  remains 
normal. 

The  contracture  seldom  ends  at  once,  usually  being  of  a 
protracted  course,  that  is,  the  contracture  disappears  to  appear  again, 
while  such  changes  may  take  place  several  times  a  day,  the 
periods  of  contracture  lasting  in  general  longer  than  the  inter- 
vals. 

Besides  the  characteristic  contractures  three  more  symptoms 
are  almost  always  met  with,  which  are  specially  peculiar  to  this 
disease: — Trousseau's  syiuptoui — the  appearance  of  contracture 
of  the  fingers  and  wrist  upon  compression  of  the  brachial  artery 
or  brachial  plexus:  this  compression  (constricting  the  shoulder 
with  a  twisted  handkerchief)  being  performed  during  the  in- 
terval; Chovstek's  syinpfom  or  facial  pheuomenou — twitching 
of  the  angle  of  the  mouth  and  other  facial  muscles  upon  slight 
percussion  with  the  hammer  upon  the  facial  nerve  (immediately 
in  front  of  the  ear).  This  phenomenon  is  based  upon  the  fact 
that  in  tetany  there  is  generally  noted  a  strongly  increased  ex- 
citability of  the  muscles  to  mechanical,  as  well  as  to  the  electrical 
(galvanic  current)  irritations;  the  latter  constitutes  Evh's  symp- 
tom. 

These  three  symptoms  ma}-  be  used  for  determining  the 
latent  form  of  tetany  when  the  patient  has  no  contractures,  for 
instance,  during  the  intervals  between  the  attacks. 

Of  complications  of  tetany  the  chief  is  laryngismus  stridulus 
occurring  in  this  malady  so  often  that  it  is  held  by  some  authors 
to  be  a  manifestation  of  tetany  itself.  Indeed,  one  often  suc- 
ceeds in  detecting,  in  children  suffering  with  laryngismus  stridu- 
lus but  entirely  free  from  contracture  of  the  fingers,  either  the 
facial  phenomenon,  or  the  symptoms  of  Trousseau  and  Erb,  or 
even  all  these  three  symptoms  together,  but  this  being  not  always 
the  case,  one  cannot  hold  all  cases  of  laryngismus  stridulus  as 
latent  tetany. 


370  DISEASES    OF    THE    NERVOUS    SYSTEM 

As  to  the  course  of  tetany,  one  may  say  in  general  that  the 
whole  disease  lasts  approximately  from  a  few  days  up  to  six 
weeks,  ending-  usuallx'  with  recovery,  but  laryngismus  stridulus 
being  present  a  fatal  termination  may  easily  come  on. 

In  the  aetiology  of  tetany  two  conditions  play  the  main  part : 
the  age,  from  six  months  up  to  three  years,  and  rachitis,  which 
occurs  in  tetany  almost  always,  therefore  some  authors  hold  tetany 
as  one  of  the  symptoms  of  rachitis. 

Of  the  accidental  or  exciting  causes  the  most  important  are — 
subacute  or  chronic  catarrhs  of  the  intestines  and  different 
febrile  diseases,  especially  those  of  the  respiratory  organs. 

In  view  of  what  has  just  been  said  the  diagnosis  of  typical 
cases  of  tetany  is  not  difficult  as  the  symmetrical  contracture 
of  the  hands  and  fingers,  with  the  complete  preservation  of  con- 
sciousness and  the  periodical  course,  does  not  occur  in  any  other 
disease.  If  the  physician  sees  the  patient  in  the  period  of  an 
interval  and  suspects  tetany  on  the  ground  of  the  history,  then 
he  may  become  sure  of  the  diagnosis  by  the  aid  of  the  symptoms 
of  Trousseau  and  Chvostek.  In  the  same  manner  he  may  detect 
a  latent  tetany  in  children  suft'ering  seemingly  only  witli  laryngis- 
nuis  stridulus. 

In  those  rare  cases  where  spasm  entirely  involves  all  the 
limbs  and  the  muscles  of  the  trunk,  then  such  condition  may  be 
easily  taken  for  tetanus.  The  marked  dift'erence  consists  in  that 
in  such  disease  the  masticators  ( trismus )  become  affected  most 
severely  and  the  earliest,  then  the  muscles  of  the  nape  of  the 
neck  and  those  of  the  spine  (opisthotono.'O.  while  the  wrists  and 
the  fingers  are  either  not  involved,  or  very  slightly,  whereas  in 
tetany  the  opposite  obtains — the  hands  are  involved  at  first,  the 
chewang  muscles  remaining  unaffected  even  in  those  rare  and 
grave  forms  of  tetany  wherein  the  spasm  spreads  to  the  muscles 
of  the  occiput  and  trunk.  Furthermore,  in  tetanus  the  reflex 
excitability  is  strongly  exaggerated,  but  there  are  absent  the 
symptoms  of  Trousseau,  Chvostek  and  Erb.  Finally,  attention 
should  also  be  given  to  the  aetiology  of  the  case ;  in  tetanus — 
a  wound;  in  tetany — rachitis,  laryngismus  stridulus,  age,  fever  or 
some  disorder  of  digestion. 


i)isi:.\si:s  (IF  Till-:  nervous  system  371 

CONTRACTL'RE  OF  THE  NECK  MUSCLES. 

Immobility  of  the  neck  because  of  contracture  of  the  neck 
muscles  occurs  in  children  quite  often.  If  the  posterior  neck 
muscles  be  contracted,  then  the  head  is  thrown  back  (contracture 
of  the  nape  of  the  neck),  and  the  neck  forms  a  concavity  on  its 
posterior  surface ,  if.  however,  the  muscles  of  one  side  are  con- 
tracted, then  ihe  head  is  turned  toward  the  corresponding  shoulder 
(wry-neck — torticollis).  In  slight  degrees  of  contracture  of  the 
neck  the  liead  is  not  thrown  back,  but  remains  extended  and 
cannot  be  passively  bent,  and  each  attempt  at  so  doing  is  very 
painful,  so  that  even  in  somnolency  due  to  meningitis,  when 
pricks  with  the  needle  do  not  produce  any  reaction,  children  with 
the  contracted  neck  react,  upon  the  passive  bending  of  the  head, 
either  with  groaning  or  disfiguration  of  the  face. 

To  recognize  contracture  of  the  neck,  even  in  slight  degree, 
is  not  difficult  even  in  the  smallest  children ;  one  has  only  to  try 
bending  the  child's  head  when  he  is  in  a  recumbent  posture  on  his 
back ;  if  the  contracture  of  the  neck  he,  absent,  then  it  is  easy  to 
bend  the  head  to  the  chest,  on  the  contrary  the  whole  trunk  rises 
together  with  the  head,  which  remains  stretched. 

Acute  varieties  of  contracture  of  the  neck  most  often  occur 
during  different  forms  of  Dwiiiiii^itis  and  especially  in  epidemic 
cerebro-spinal  inflammation  of  the  meninges,  in  the  diagnosis 
of  v.-hicli  contracture  of  the  neck  appears  as  a  very  important 
sxmptom,  because  it  developes  very  early,  together  with  other 
symptoms  of  irritation,  in  the  first  period  of  meningitis  ;  so  that, 
if  we  have  a  patient  who  only  one  or  two  days  previously  became 
ill  with  fever  and  headache  and  who  complains  of  severe  back- 
ache, increasing  upon  each  movement  and  especially  upon  bend- 
ing the  spine  (change  of  the  recumbent  posture  into  a  sitting 
one)  and  if  he  has  contracture  of  the  neck,  then  cerebro-spinal 
meningitis  may  be  diagnosticated,  even  if  the  consciousness  be 
not  yet  impaired  and  constipation,  as  well  as  retarded  pulse,  be 
absent. 

In  tubercular  meningitis  or  in  acute  simple  hydrocephalus, 
contracture  of  the  neck  is  not  unusual,  although  not  occurring 
from  the  first  days  of  the  disease,  but  later,  namely  in  the  period 
of  somnolency  and  impairment  of  consciousness.     One  may  then 


372  DISEASES    OF    THE    XERVOUS    SYSTEM 

note  in  llic  liistory  that,  ten  days  previous  to  the  appearance  of 
the  contracture  of  the  neck  and  somnolency .  in  the  child,  there 
was  a  persistent  (usually  of  many  days'  duration)  vomiting  and 
constipation  with  mild  fever  and  retarded  pulse. 

If  the  contracture  of  the  neck  appears  in  the  patient  several 
days  after  a  violent  fever,  then  on  the  ground  of  this  symptom 
the  diagnosis  of  meningitis  cannot  be  made  even  in  case  the 
patient  is  in  the  state  of  somnolency,  half-consciousness,  or  de- 
lirium, and  if  there  be  clearly  developed  general  hypersesthesia 
of  the  skin,  because  just  the  same  picture  may  be  met  with  in 
grave  cases  of  typhoid  and  relapsini^  fever.  High  temperatures 
(40  degrees  C.  or  104  degrees  F.  and  more)  are  peculiar  to 
severe  cases  of  these  diseases,  considerably  assisting  the  diagnosis. 
That  the  patient  is  not  suffering  with  a  cerebro-spinal  meningitis, 
one  may  see  from  the  contracture  of  the  neck  having  appeared  too 
late  (for  instance,  in  the  second  week)  ;  against  tubercular  men- 
ingitis there  is  the  too  elevated  temperature  and,  perhaps,  the 
absence  of  initial  vomiting  (which  does  not  often  occur  during 
tvphoid  or  typhus  and  in  relapsing  fevers,  being  never  persist- 
ent). It  is  obvious  that,  if  the  physician  can  convince  himself  of 
the  existence  in  the  patient  of  a  recent  spleen-tumor  and  typhoid 
rose-spots,  then  the  diagnosis  of  typhoid  will  be  easy. 

It  very  seldom  occurs  that  contracture  of  the  neck  compli- 
cates tvphoid  from  the  very  first  days  of  the  disease;  and  in 
such  a  case  the  diagnosis  remains  in  doubt  for  a  few  days.  I 
have  had  the  opportunity  of  observing  only  one  such  case,  in  a 
lewish  bov.  aged  six  years,  because  of  complication  of  typhoid 
with  acute  rheumatism  of  the  neck  muscles  (the  patient  had 
also  previously  suffered  with  contracture  of  the  neck  muscles). 
Cerebro-spinal  meningitis  in  this  case  could  be  excluded  in  view 
of  the  absence  of  pain  in  the  back,  hxpersesthesia  of  the  skin  and 
initial   vomiting. 

If  the  immobility  of  the  head  because  of  contracture  of  the 
neck-muscles  occurs  in  the  chronic  form,  then  it  almost  always 
depends  upon  spondylitis  in  the  cervical  portion  of  the  vertebral 
column ;  the  head  in  such  cases  is  not  thrown  back,  but  remains 
extended  (see  the  section  on  Pott's  disease). 

Acute  forms   of  lateral  curvature  of  the   neck    (torticollis) 


DISEASES    OF    THE    XERX'OUS    SYSTEM  373 

most  often  occur  in  rhciniiafisni  of  the  stcniO'Cleido-niastoid 
muscle  or  of  the  trapezius  or  splcnii.  In  contracture  of  the  sterno- 
cleido-mastoid  muscle  the  head  bends  toward  the  affected  muscle, 
while  the  face  is  turned  toward  the  opposite  side  and  the  chin 
somewhat  rises.  In  unilateral  contraction  of  the  trapezius  muscle 
the  head  is  also  bent  toward  the  affected  side  and  somewhat 
back,  but  sinmltaneously  the  corresponding  shoulder  is  elevated  : 
in  case  the  splenii  become  involved,  the  chin  is  not  raised,  and  the 
face  does  not  turn  toward  the  unaffected  side,  but  the  head  is 
simj)ly  inclined  toward  the  shoulder  of  the  involved  side. 

The  diagnosis  is  assisted  still  further  by  the  affected  muscles 
being  felt  as  more  solid  and  tense  than  normal. 

One  mav  diagnose  rheumatism  of  the  neck  nuiscles  only 
when  the  absence  of  painfulness  in  the  vertebr.-e  excludes  synovi- 
tis vertebralis  and  if  there  are  no  signs  of  inflammation  of  the 
neck-glands,  cellular  tissue  or  a  retro-pharyngeal  abscess,  in 
which  a  changed  posture  of  the  head  is  often  observed.  In  reality, 
torticollis  rheumatica  probably  occurs  not  so  often  as  it  is  com- 
monly believed,  as  the  majority  of  cases  included  in  this  category 
show  upon  closer  examination  of  the  vertebral  column  nothing 
but  s}novitis  (spondylarthritis  cervicalis  of  \'olkmann)  of  the 
lateral  articulations  of  the  vertebral  column.  These  synovites 
may  be  of  rheumatic  or  traumatic  origin,  or  they  develop  after 
some  infectious  diseases,  especiall}-  after  scarlet  fever.  The 
similarity  to  rheumatic  torticollis  is  striking  the  n^ore  the  posture 
of  the  head  corresponds  to  the  unilateral  contracture  of  the  sterno- 
cleido-mastoid  muscle  ;  the  head  is  turned  toward  the  well  side, 
the  face,  however,  to  the  affected  one,  the  chin  being  somewhat 
elevated.  The  diagnosis  is  easily  determined  by  the  contracted 
muscle  being  painless,  while  pressure  produces  sharp  pain  when 
applied  to  one  part  of  the  spinous  processes. 

Torticollis  sometimes  arises  in  the  form  of  periodically  re- 
lapsing attacks  rapidly  yielding  to  c|uinine,  that  is,  it  must  be 
looked  upon  as  febris  intermittens  larvata. 

Chronic  cases  of  lateral  curvature  oi  the  neck  may  have  an 
i)iheritcd  ori_i^iii  (because  of  rupture  of  the  sterno-cleido-mastoid 
muscle  during  labor),  and  then  the  half  of  the  head  correspond- 
ing to  the  contracted  nmscle,  shows  a  noticeable  degree  of  atrophy 
or  lack  of  development. 


SEMEIOLOGY   OF   THE    PARALYSES. 

I'nder  the  name  of  paralysis  is  understood  inability  of  per- 
forniini;-  voluntar\-  movements,  depending  either  n])on  the  destruc- 
tion of  the  conductibility  of  the  vohmtary  impulses  along  the 
nervous  elements  (neurophathic  paralysis),  or  upon  the  loss  of 
muscular  coiitractibility  due  to  disease  of  the  muscle  itself  ( m}o- 
pathic  paralysis).  Therefore,  one  nuist  not  make  a  diagnosis 
of  paralysis  only  because  the  child  holds  immovable  this  or  the 
other  extremitN ,  but  nuist  prove  that  this  immobility  depends  upon 
disorder  of  innervation  of  the  neuro-muscular  apparatus,  and  does 
not  depend,  for  instance,  upon  pain  from  inflammation  of  the 
joint,  or  upcTn  bone  lesion,  etc. 

In  childhood,  as  well  as  in  adult  life,  the  paralyses  are  of 
diiferent  character,  depending  upon  the  parts  of  the  nervous  sys- 
tem involved ;  if  the  paralysis  depends  upon  disease  of  the  motor 
portions  of  the  cerebral  cortex  or  pyramidal  tracts  oi  the  brain 
or  spinal  cord,  then  it  is  characterized  by  the  peculiarities  of 
so-called  central  paralysis,  if,  however,  the  afifection  occupies  the 
anterior  columns  of  gray  matter  of  the  spinal  cord  (nuclear 
paralyses  in  the  strict  sense  of  the  word),  then  we  have  the 
l)eculiarities  of  peripheral  paralysis. 

The  main  differences  between  central  and  peripheral  ])aral\ses 
are  as  follows  : — 

(i)  The  spread  of  the  paralysis — diffuse  paralysis,  especially 
the  paralysis  of  one-half  of  the  body,  indicates  a  central  origin, 
while  the  paralysis  of  single  muscles  or  muscle-groups,  in  short, 
limited   paralysis,  denotes  its   peripheral   nature. 

(2)  The  relation  of  the  paralysed  niuseles  to  the  electrical 
current. 

In  central  paralyses  the  reaction  of  the  nerves  and  muscles 
to  electrical  irritation,  with  the  constant,  as  well  as  with  the  in- 
terrupted current,  does  not  exhibit  any  changes,  at  least  in  quite 


nisi':.\si-:s  of  tiii-:   xi^rvots  s^■s■|"KM  375 

recent  cases  (  for  instance,  two  or  three  months)  ;  later  on,  how- 
ever, the  electrical  excitability  changes  only  ((uantitatively,  bnt 
not  (jualitativelx ,  that  is,  it  merely  lowers.  On  the  contrary,  in 
nnclear  and  purelx  ])eri|)heral  paralyses  the  faradic  e.xcitaliility 
in  the  nerves,  as  well  as  in  the  mnscles,  rapidly  begins  to  fall 
within  a  few  days  after  the  development  of  the  paralysis.  In 
regard  to  the  galvanic  current  the  nervous  excitability  also  falls, 
and  upon  the  direct  irritation  of  the  muscles  there  is  not  only 
quantitative  lowering  of  the  excitabilitw  but  also  its  (pialitative 
alteration,  which  is  expressed  by  the  perversion  of  the  physiologi- 
cal law  of  muscle-contraction  upon  closure  and  opening  of  the 
current.  Normalh  a  muscle  reacts  to  a  weak  current  by  rapicl 
twitching  at  the  moment  of  cathode  closure  [C  C.  C. — cathode 
closure  contraction)  ;  if  the  current  be  gradually  increased,  then 
similar  sudden  contractions  begin  to  appear  also  upon  the  closure 
and  opening  of  the  anode,  being  stronger  upon  cathode-closure 
(C  C  C>A  C  C  and  A  O  C,  that  is  cathode  closure  oontractiou 
is  more  than  anode  closure  contraction  and  anode  opening  con- 
traction) ;  if  the  strength  of  the  current  be  further  incfeased, 
then  contraction  also  appears  upon  cathode  opening.  It  means 
norniall}'  cathode  closure  irritates  the  nuiscles  stronger  than 
cathode  opening,  but  in  pathological  cases  of  which  we  now  speak 
we  obtain  perversion  of  this  law  known  as  reaction  of  dc<:;cncra- 
tioii.  This  reaction  is  characterized  by  the  fact  that  the  hr>t 
contraction  of  the  muscles,  upon  the  gradual  increasing  of  the 
weakest  current,  sets  in  at  the  anode-closure,  then,  the  current 
being  made   stron'^er,   at   the   cathode-closure    (ACC>CCC) 

Besides  this,  the  character  of  the  contraction  of  muscles 
changes;  instead  of  a  sudden  contraction  we  obtain  a  sluggish, 
continuous  one.  Toward  the  time  of  the  disappearance  of  the  re- 
action of  degeneration  the  faradic  excitabilit\-  in  the  nerves  and 
muscles  usually  disappears  altogether.  .Although  the  reaction  of 
.degeneration  always  points  toward  the  ])erii)heral  (or  nuclear) 
origin  of  the  paralysis,  yet  is  not  necessary  to  the  latter  at  all, 
so  that  absence  of  reaction  (^f  degeneration  dfies  not  admit  of  a 
contrary  conclusion. 

(3)  The  condition  of  the  muscles.  The  muscular  tonus  dur- 
ing paralvsis  mav  appear  increased  or  decreased  ;  in  the  former 


3/6  DISEASES    OF    THE    NERVOUS    SYSTEM 

case  the  paralyzed  muscles  are  visibly  tense  and  solid  to  touch, 
in  the  latter  they  are  enfeebled  and  flal)by. 

Increase  of  the  muscular  tonus  occurs  in  central,  and  a  weak- 
ening; in  peripheral  and  nuclear  paralyses. 

Atrophy  of  the  paralyzed  iiiiiscles  sets  in  very  soon  in 
peripheral  paralyses  and  very  slowly  in  central. 

(4)  The  tendon  reflexes  in  the  case  of  a  complete  paralysis 
are  retained  only  in  the  case  of  central  origin.  As  the  tendon 
reflexes  are  exaggerated  during  any  increase  of  the  muscular 
tonus,  then  all  spastic  paralyses  are  also  of  central  origin,  while 
the  peripheral  (or  nuclear)  paralysis  characterized  by  weaken- 
ing of  the  muscles,  that  is,  by  lowering  of  their  tonus,  is  ac- 
companied by  the  considerable  decrease  or  complete  disappear- 
ance of  the  tendon  reflexes.  The  preservation  of  the  cutaneous 
reflexes  is  more  peculiar  also  of  central  paralyses. 

T  cannot,  of  course,  enter  into  the  minute  discussion  of  all 
possible  ])aralyses,  which  would  take  us  too  far  into  the  field  of 
neuropathology,  referring  the  reader,  regarding  these  questions, 
to  the  text-books  u])()n  nervous  diseases.  My  purpose  here  will 
be  limited  to  a  siiort  description  of  the  differential  diagnosis  of 
the  paralyses  which  are  peculiar  to  childhcxid  in  particular. 

PARALYSES   W  ITH    FLACCIDITY  OF  THE   MUSCLES. 

Infantile  i-araiasis  or  multiple  inflammation  of  the  an- 
terior cornua  of  gray  matter  of  the  spinal  cord,  polioinyelit'S 
anterior  acutissima.  s.  paralysis  spinalis  i)ifa}itiiin,  s.  paralysis 
essentialis.  This  peculiar  paralysis  dependent  upon  the  extreme- 
ly acute  inflammation  of  the  anterior  gray  columns  of  the  spinal 
cord,  is  called  "infantile,""  because  it  occurs  almost  exclusively 
in  small  children,  especially  during  the  first  or  the  second  year 
of  life,  being  somewhat  rare  at  the  age  of  three  or  four  years, 
much  rarer  in  children  after  six  years  and  only  as  a  very  marked 
exception  in,  adult  persons.  This  circumstance  has,  of  course, 
also  a  diagnostic  value.     (Figs.  37  and  38.) 

The  aetiology  of  the  disease  is  obscure;  no  cause  (infection?) 
can  be  found  in  the  great  majority  of  cases ;  in  other  instances 
spinal  paralysis  develops  after  a  cold  or  after  acute  febrile 
diseases. 


DISEASES    OF    THE    NERVOUS    SYSTEM 


377 


Spinal  infantile  paralysis  is  distinouished  by  the  following 
peculiarities : — 

(i)  It  develops  suddenly  when  the  patient  is  seemingly  in 
the  best  of  health  (for  instance,  the  child  went  to  bed  healthy, 
but  awoke  with  the  paralysis  of  one  or  several  extremities)  ;  or 
after  a  prodromal  period  of  three  to  five  days'  duration,  in  which 
the  patient  was  in  a  moderately  febrile  condition  (38  to  39  de- 
crees C. — or  100.4  degrees  to  102.2  degrees  F.)  ;  not  very  unconi- 


pig.  2)7 — Section  through  the  cervical  enlargement  of  the  spinal  cord  in 
poHomyelitis  anterior  acuta;  the  left  anterior  gray  horn  is  very  much 
contracted  and  is  without  gang  ion-cells    (After  Charcot  and  Jafifroy). 

monly  the  onset  of  the  disease  is  marked  by  vomiting  and  repeat- 
ed, or  but  one,  attacks  of  eclampsia.  When  the  febrile  condition 
ceases,  after  a  few  days,  then  the  paralysis  is  already  well-de- 
veloped. 

(2)  In  the  beginning  the  paralysis  is  usually  wide-spread 
involving,  for  instance,  all  four  extremities  or  even  the  muscles 
of  the  trunk  (kyphosis  and  scoliosis)  ;  but  during  the  following 
weeks,  and  even  days,  many  of  the  paralyzed  inuscles  return  to 
the  normal  condition,  and  the  paralysis  may  finally  be  confined  to 
•only  one  limb,  and  then  not  to  the  whole  extremity,  but  only 
to  some  of  the  muscles,  remaining  therein  fixed  for  a  long  time 
or  even  permanently.  The  longest  term  after  which  one  may 
yet  hope  the  paralysis  will  disappear  is  held  to  be  approximately 


378 


DISEASES    OF    THE    NERVOUS    SYSTEM 


nine  months  ;  in  other  words  whatever  cHsahihty  remains  after  nine 
months  will  remain   permanently. 

(3)  During  infantile  paralysis  seusibility  of  the  skin,  as  well 
as  of  the  vesical  and  rectal  sphincters,  is  never  involved.  If 
in  the  area  of  the  paralysis  some  disorders  of  sensibility  are  ob- 
served, these  being-  pain,  anaesthesia,  or  hypera^sthesia,  then  one 
mav  be  sure  that  the  case  is  not  poliomyelitis  anterior.  Should 
any  disturbance  of  micturition  occur,  as  may  perhaps  rarely,  then 


Fig.  38 — Acute  spinal  infantile  paralysis.      Iransverse  section  through  the 
lumbar  enlargement  of  the  spinal  cord  (After  Charcot). 

it   is  onlv   during  the  tirst  days  of  the  disease  and   for  a   short 
time. 

(4)  The  paralyzed  muscles  are  always  in  a  flaccid  condition, 
therefore  the  tendon  reflexes  are  either  entirely  abolished  or  con- 
siderably lessened  (retained  in  the  paralyzed  muscles). 

In  the  further  course  of  the  disease  three  more  important 
signs  appear : — 

(5)  Muscular  atrophy,  noticeable  within  two  weeks  from  the' 
beginning  of  the  paralysis. 

(6)  The  quick  fall  of  the  faradic  excitability  in  the  nerves- 


Disi'iAsi'is  (I I'    I' 111-:   .\i:k\()rs 


379 


and  muscles  of  tlie  paralyzed  extremity  and  the  appearance  of 
reaction  of  degeneration.  (The  lowering-  of  the  electrical  ex- 
citability may  be  observed  after  a  few  da\s.  and  after  about  two 
weeks  there  also  appears  reaction  of  degeneration  in  the  most 
affected  muscles).      If   the   electrical   excitability   in   the  nerves, 


Fig.  30 — Anierinr  iiDlioniyi  litis,   sliowmg  atrophy  and   sligiit   lateral  curva- 
ture (if  the  spine   (Whitman). 

as  well  as  in  the  nniscles.  disai)pears  altogether  and  does  not 
return  even  after  the  lapse  of  eight  or  ten  months,  it  is  a  very 
bad  omen,  denoting  the  incurability  of  the  paralysis. 

(7)    Trophic  disturbances  are  manifested  by  the  consider- 
able  wasting   of   the   extremitv.    togetlier   with    lowering   of   the 


380  DISEASES    OF    THE    NERVOUS    SYSTEM 

temperature  of  tlic  skin.  On  the  contrary  bed-sores  are  never 
present. 

As  the  paralysis  is  not  locahzed  in  all  muscles  of  the  limb, 
but  only  in  some,  then  in  time  a  deformity  usually  develops  due 
to  contraction  of  the  healthy  muscular  antagonists.  In  the  leg"  a 
permanent  paralysis  of  the  peroneus  longus  most  often  remains, 
in  the  arm  of  the  deltoid. 

In  anterior  poliomyelitis  the  permanent  paralysis  most  often 
affects  one  limb  (two-thirds  of  all  cases),  namely  the  leg — 
monoplegia ;  less  frequently  both  legs  become  paralyzed — 
paraplegia;  still  more  seldom  both  arms  (paraplegia  cervicalis) 
or  the  arm  of  one  side  and  the  leg  to  the  other  one  (paralysis 
cruciata) , 

In  consideration  of  these  signs  the  diagnosis  of  spinal  paraly- 
sis is  not  difficult. 

Of  recent  eases  most  like  spinal  paralysis  we  have  the  uni- 
lateral cereljral  infantile  paralysis  descrilx-d  by  Striimpell  under 
the  name  of  polioencei'IIaliits  acuta,  the  anatomical  essence 
of  which  consists,  in  his  opinion,  in  acute  inriammation  with  the 
consequent  sclerosis  and  atrojihy  of  the  gray  matter  of  the  cere- 
bral cortex,  but  in  reality  the  inflammation  is  not  limited  only 
to  the  gray  matter,  as  in  poliomyelitis,  but  usually  involves  the 
white   matter   also. 

The  resemblance  between  recent  cases  of  cerebral  and  spinal 
paral\ses  consists  in  the  following: — 

(  I )  Both  are  met  with  more  often  in  children  of  the  first 
three  years  of  life,  while  the  cause  of  the  disease  usually  remains 
unknown.  (Striimpell's  opinion  that  in  both  cases  we  have  to 
deal,  probably,  with  the  influence  of  some  infection  which  in 
some  cases  is  localized  in  the  gray  matter  of  the  spinal  cord,  in 
others  in  that  of  the  brain,  was  confirmed  by  Moebius'  observa- 
tions : — In  one  family  two  children  became  sick  at  the  same  time 
with  paralysis  ;  in  one  of  them  poliomyelitis  anterior  was  found, 
in  the  other  polioencephalitis.)* 

(2)  The  paralysis  develops  quickly  after  a  febrile  period  of 
several  days"  duration,  which  starts  with  vomiting  and  convul- 
sions (both  the  latter  symptoms  may  be  absent  not  only  in  spinal, 
but  also  in  cerebral  paralysis). 

*Medic.  Obozr.    Vol.  XXVI.,  page  891. 


DISKASES    OF    T}1K    NERVOUS    SYSTEM  381 

(3)  In  botli  cases  the  ])aralysis  may  ])e  localized  in  one  entire 
extremity  or  only  in  some  muscles  of  the  same. 

(4)  The  sensibility  of  the  skin,  as  well  as  of  the  bladder  and 
rectum,  remains  intact. 

Nevertheless  the  diiTerential  diagnosis  is  in  most  cases  not 
difficult,  being-  based  upon  the  following  data : — 

(i)  Cerebral  i)aralysis  is  always  unilateral  and  appears  in 
the  form  of  hemiplegia  as  soon  as  two  extremities  are  involved. 
This  is  the  most  frequent  form.  If,  however,  only  one  limb  be 
paralyzed,  then  it  is  oftener  the  arm  than  the  leg;  while  in  spinal 
paralysis  there  is  most  often  paralyzed  either  only  one  leg,  or 
both  legs,  but  very  seldom  only  one  arm. 

(2)  Sometimes  the  facial  nerve  or  the  eye-muscles  (strabis- 
mus) become  paralyzed  in  the  cerebral  form. 

(3)  Muscular  atrophy  and  lack  of  development  of  the 
paralyzed  limbs  develop  much  slower  and  do  not  reach  such  an 
extent  in  cerebral  as  in  spinal  paralysis.  A  noticeable  coolness 
of  the  extremities  and  the  cyanotic  tint  of  the  integument  are 
peculiar  only  of  spinal  paralysis. 

Of  further  special  importance  in  the  differential  diagnosis 
are: 

(4)  In  cerebral  paralysis  reaction  of  degeneration  never 
occurs  in  paralyzed  muscles ;  on  the  contrary,  not  only  the  galva- 
nic, but  also  the  faradic  nervous  and  muscular  excitability  are 
completely  conserved  for  a  long  time,  while  in  the  spinal  form 
both  rapidly  diminish. 

(.S)  The  paralyzed  muscles  are  not  flaccid  but  noticeably 
tense  (therefore  the  cerebral  paralyses  bear  the  name  of  "spastic 
hemiplegise"),  therefore  also  the  tendon  reflexes  are  considerably 
exaggerated. 

(6)  Motor  symptoms  of  irritation  are  often  observed  in  the 
patient  either  in  the  form  of  a  common  or  a  cortical  epilepsy 
(unilateral  convulsion  on  the  side  of  the  paralysis  without  loss 
of  consciousness),  or  in  the  form  of  athetosis  and  chorea.  Some- 
times the  speech  ability  suffers.  As  to  the  mental  capacity  this 
does  not  exhibit  constant  changes.  In  some  cases  of  cerebral 
paralysis  the  intellect  remains  normal,  in  others  more  or  less  im- 
paired ;  if  the  patient  suffering  with  spastic  hemiplegia  begins  to 
have  epileptic  fits  (they  do  not  appear  sinndtaneously  with  hemi- 


382  DISEASES    OF    THE    NERVOUS    SYSTEM 

plegia,  but  after  some  time,  the  duration  of  which  varies  from 
a  few  weeks  to  many  months),  then  one  may  be  sure  that  the 
psychical  condition  of  such  a  patient  will  not  remain  normal. 

Besides  polioencephalitis  the  rapid  development  of  hemi- 
plegia may  be  also  caused  b\-  cerebral  haemorrhage  or  embolism 
of  the  cerebral  vessels.  In  adults,  as  well  as  in  children,  hemi- 
plegia of  such  origin  is  characterized  by  its  sudden  onset  without 
prodromal  fever,  but  in  the  presence  of  certain  setiological  factors. 
Thus  in  embolism  lesion  of  the  cardiac  valves  may  be  of  import- 
ance ;  in  haemorrhage  severe  attacks  of  cough,  as,  for  instance,  in 
whooping-cough  ;  temporary  haemophilia,  as  in  Werlhof 's  disease ; 
disorders  of  respiration  and  circulation  because  of  convulsions ; 
in  all  these  cases  the  picture  of  the  disease  will  be  the  same  as 
that  in  polioencephalitis  (see  page  399). 

In  long-standing  cases,  that  is,  in  the  period  of  atrophy  of 
the  paralyzed  muscles,  the  following  may  be  mistaKen  for  polio- 
myelitis : 

1.  Polyneuritis. 

2.  Acute  myelitis. 

3.  Progressive  muscular  atrophy. 

4.  Chronic  inflammation  of  the  spinal   meninges. 

5.  Weakness  of  the  legs  in  rachitic  patients. 

The  symptoms  of  separate  cases  of  polyneuritis,  or  multiple 
inflammation  of  the  peripheral  nerves,  vary  very  much,  depend- 
ing upon  whether  the  motor  or  sensory  fibers  are  affected  prin- 
cipally, or  both  equally.  Also  of  great  importance  here  is  the 
aetiology,  upon  which  there  depends  the  localization  of  the  morbid 
process ;  as,  for  instance,  in  lead  neurites  the  motor  fibers  sup- 
plying the  extensors  of  the  forearm  and  the  wrist  become  almost 
exclusively  affected ;  in  alcoholic  neurites  the  lower  limbs  are 
especially  involved,  while  the  chief  symptom  is  severe  pain.  In 
diphtheritic  neurites   the   soft  palate  becomes   affected,  etc. 

Briefly,  the  varieties  are  many,  yet  in  but  few  forms  of 
neurites  is  there  reason  for  their  being  confounded  with  polio- 
myelitis. The  greatest  similarity  to  the  latter  is  presented  by 
cases  of  polyneuritis  which  appear  in  healthy  persons  without  any 
apparent  cause,  or  after  an  exposure  to  cold,  in  short,  in  the 
form  of  an  independent,  primary,  probably  infectious  disease; 
and  sometimes  the  same  form  of  polyneuritis  develops  as  a  sub- 


nisEAsi:s  OF  Tiih:  .\i:K\;)rs  systkm  383 


se(|ncnt  disease  following-  some  (Iciinitc  infectious  ])r()cess  (tvphoid 
fever,  snnll-i)ox.  etc.). 

(a)  Primary  multiple  inflammation  of  the  nerves — 
neuritis  )nultiplcx — occurs  in  childhood  jirobably  much  oftener 
than  one  would  think  to  judge  from  the  scanty  literary  data.  The 
resemblance  to  |)olyneuritis  consists,  chieily,  in  that  the  paralysis 
has  in  both  cases  the  properties  of  peripheral  ])aralysis,  that  is, 
the  electrical  excitability  to  both  currents  rai)idly  falls  in  the 
affected  nerves  and  muscles,  and  then  disappears  entirelv,  or 
reaction  of  degeneration  appears.  The  paralyzed  muscles  are 
flaccid,  soon  undergoing  atrophy ;  the  tendon  and  cutaneous  re- 
flexes are  lowered  or  abolished  ;  the  bladder  and  rectum  are  not 
affected.  There  is  some  resemblance  also  in  the  etiology  (ex- 
posure   to    cold,    infectious    diseases). 

As  a  pathognomonic  symptom  of  polyneuritis  by  which  the 
latter  strikingly  differs  from  poliomyelitis,  we  may  point  out 
the  severe  pain  appearing  in  the  affected  limbs  from  the  very 
beginning  of  the  disease,  and  to  the  painful  sensitiveness  upon 
pressure  over  the  nerve  branches  and  the  muscles  in  the  region 
of  the  paralysis ;  which  sensitiveness  remains  in  the  nerves  for  a 
long  time  even  in  the  period  of  atrophy. 

The  further  differences  consist  in  the  following : — poly- 
neuritis is  usually  bilateral  and  sy})i metrical,  the  paralyses  being 
more  pronounced  in  the  periphery  of  the  limbs;  in  the  legs  the 
small  peroneal  nerve  (the  plantar  flexure  of  the  foot  is  impos- 
sible) most  often  becomes  affected ;  in  the  arms,  the  extensors 
of  the  wrist.  Generally  speaking,  the  lower  limbs  become  affect- 
ed more  severely  than  the  upper.  Simultaneously  with  the 
paralyses  there  is  usually  observed  a  greater  or  less  degree  of 
ataxia,  that  is,  disorders  of  co-ordination  of  movements. 

In  some  cases  this  symptom  is  the  most  prominent  one. 
exhibiting  the  picture  of  acute  ataxia,  about  which  we  shall  speak 
later  on. 

Neuritis  begins  with  fever,  which  is  higher  and  keeps  up 
much  longer  than  in  poliomyelitis  ( in  this  disease — five  or  six 
days,  while  in  the  former,  in  polyneuritis,  frequently  several 
weeks)  ;  polyneuritis  does  not  especially  aff'ect  children  of  the 
first  years  of  life ;  the  sensibility  of  the  skin  in  this  disease  in- 
creases  to   the   degree   of   considerable   hypenTesthesia,    which    is 


384  DISEASES    OF    THE    NERVOUS    SYSTEM 

replaced  by  a  complete  or  incomplete  ansesthesia  or  different 
parsesthesise,   as  crawling  of  ants,  numbing  of  the  fingers,  etc. 

Paralysis  in  neuritis  multiplex  develops  after  the  pain,  ap- 
pearing not  at  once  very  markedly,  but  gradually  spreading  to 
new  groups  of  muscles,  beginning  from  the  periphery  (leg  and 
forearm,  then  the  thigh  and  the  shoulder),  while  in  poliomyelitis 
the  contrary  obtains  ;  in  the  beginning  a  greater  number  of  muscles- 
become  affected,  but  later  on  the  region  of  the  paralysis  gradually 
decreases.  Paralyses  in  neuritis  may  disappear  entirely  even  in 
cases  of  complete  loss  of  the  electrical  excitability,  which  in 
poliomyelitis  is  usually  absent.  The  dift'erence  can  be  explained 
by  the  fact  that  the  regeneration  of  the  inflammatory  degenerated 
nerves  is  performed  comparatively  easily,  while  regeneration  of 
the  cells  of  gray  matter  of  the  spinal  cord  is  impossible. 

In  neuritis  there  frequently  appears,  because  of  affection 
of  the  vasomotor  nerves,  cedema  of  the  feet  or  the  wrists,  which 
is  absent  in  poliomyelitis,  but  cyanosis  and  coolness  occur  in  both 
cases. 

(b)  Paralysis  with  muscular  flaccidity  sometimes  develops 
very  quickly  during  inUauimation  of  the  total  transverse  diameter 
of  the  spinal  cord  (myelitis  transversa).  In  the  muscles  corre- 
sponding to  the  destroyed  cells  of  the  anterior  cornua  there  may 
come  on  quite  ra])i(lly  not  only  lowering  of  the  electrical  excit- 
ability, but  also  reaction  of  degeneration  and  abolition  of 
cutaneous  and  tendon  reflexes.  The  similarity,  however,  is  also- 
limited  to  this,  the  differences  being  so  striking  that  it  is 
impossible  at  the  bedside  to  confuse  transverse  myelitis  with 
poliomyelitis. 

Transverse  myelitis  always  produces  paraplegia  simultan- 
eously zvith  anaesthesia,  even  if  incomplete,  from  the  upper  limit 
of  W'hich  one  may  judge  the  place  of  affection  of  the  spinal  cord,- 
as,  for  instance,  in  disease  of  the  lumbar  region  anjesthesia  ex- 
tends up  to  the  upper  boundaries  of  the  pelvis ;  when  the  lower 
dorsal  portion  is  aft'ected,  then  up  to  the  umbilicus  or  ensiform. 
process ;  if  the  upper  dorsal  portion  be  affected,  then  anaesthesia 
may  reach  the  upper  ribs ;  finally,  if  the  cervical  portion  be  in- 
volved, paralysis  and  anaesthesia  of  the  upper  extremities  ap- 
pear. 

Another  characteristic  sign  of  myelitis  consists  in  paralysis- 


DISEASES    OF    THE    NERVOUS    SYSTEM  385 

of  the  vesical  and  rcclal  sphincters.  If  the  lunihar  portion  of  the 
spinal  cord  be  healthy,  then,  although  the  bladder  and  the  rectum 
are  insensible  and  not  subordinate  to  the  will,  we,  despite  that, 
have  no  complete  incontinence,  as  the  sphincters  still  act  re- 
flexly.  As  a  peculiarity  of  paralyses  dependent  upon  myelitis 
transversa  there  may  also  be  pointed  out  the  greater  tendency 
to  the  formation  of  bed-sores  in  the  paralyzed  parts,  which  does 
not   occur    in    poliomyelitis. 

(c)  Progressive  muscular  atrophy  souietiuics  occurs  in  chil- 
dren in  manifold  forms,  of  which  the  best  known  are  the  juvenile 
atrophy  of  Erb,  the  muscular  atrophy  of  the  type  of  Landouzy 
and  Dejerine  and  pseudo-hypertrophy  of  the  muscles.  But,  as 
all  these  forms  develop  under  the  influence  of  the  same  cause, 
namely,  of  hereditary  disposition,  and  between  the  typical  repre- 
sentatives of  all  these  groups  there  exist  all  possible  transitory 
forms,  we  shall  not  describe  them  separately,  but  only  say  that 
they  all  belong  to  the  so-called  myopathic  muscular  atrophies ; 
while  the  spinal  form  of  muscular  atrophy,  dependent  upon 
chronic  degenerative  processes  in  the  anterior  columns  of  gray 
matter,  as  well  as  in  the  anterior  roots,  nervous  trunks  and  mus- 
cles, being  characterized  by  the  atrophy  involving  first  of  all  the 
wrists  (Fig.  40)  and  then  progressively  spreading  over  the  greater 
part  of  the  muscles  of  the  trunk  and  limbs  (but  not  the  face)  and 
associated  in  the  afifected  muscles  with  the  frequent  appearance  of 
fibrillar  twitchings  and  sometimes  also  reaction  of  degeneration 
(almost  never  in  myopathic  forms),  hardly  ever  occurs  in  child- 
hood, its  existence  being  not  yet  positively  proven  even  in  adults 
(Roth). 

In  all  forms  of  progressive  muscular  atrophy  (not  excluding 
the  spinal  form)  the  paralysis  sets  in  after  atrophy  and  develops 
very  slozvly;  the  electrical  excitability  in  the  paralyzed  muscles 
is  conserved  for  a  long  time,  namely,  as  long  as  some  normal 
fibers  remain ;  but,  according  to  the  development  of  the  atrophy, 
the   same   gradually   declines. 

All  these  -signs  are  entirely  sufficient  for  the  distinction  of 
progressive  muscular  atrophy  from  that  due  to  poliomyelitis. 

In  the  majority  of  cases  the  diagnosis  is  easily  made  even 
without  the  history  and  without  the  examination  of  the  electrical 
excitability,  but  directly  on  the  evidences  of  the  extension  of  the 


386 


DISEASES    OF    THE    NERVOUS    SYSTEM 


atrophy :  in  progressive  muscular  atrophy  the  process  usually 
spreads  syiiiiiictrically;  the  muscles  of  the  shoulder  and  the  trunk, 
often  become  affected,  which  is  unusual  in  poliomyelitis,  where 
some  muscles  of  one  leg  are  commonly  involved. 

Separate  forms  of  muscular  atrophy  differ  from  each  other 
by  the  following  peculiarities: — psciido-iiniscuhir  hypertrophy 
is  characterized  by  hyperplasia  of  the  interstitial  connective  and 
adipose  tissues,  by  some  muscles  becoming  noticeably  enlarged, 
notwithstanding  they  are  in  the  condition  of  paralysis  or  con- 
siderable weakness,  and  that  other  muscles  undergo  simple  atrophy 
(hypertrophy  appears  most  often  in  the  calves,  glutei,  quadriceps; 
atrophy  in  the  muscles  of  the  trunk,  scapulae  and  shoulder)   (Fig. 


Fig.  40 — A.  The  claw-like  hand  in  progressive  muscular  atrophy  (After 
Duchenne).  B.  The  claw-like  hand  in  paralysis  of  the  intercostal  mus- 
cles due  to  affection  of  the  ulnar  nerve. 

41).  As  this  disease  usually  begins  in  early  childhood,  and  first 
of  all  in  the  legs,  such  children  learn  to  walk  very  late  and  usually 
walk  badly,  especially  upstairs. 

Erb's  jnvende  form  of  atrophy  is  also  of  hereditary  origin 
and  not  infrequently  occurs  in  several  children  of  the  same  fam- 
ily, but  in  distinction  from  the  disease  just  mentioned  it  often 
begins  in  the  shoulders  rather  than  in  the  legs.  The  muscles 
mostly  affected  are  the  pectorales,  trapezius,  latissiraus  dorsi,. 
serratus  anticus  major,  rhomboidei,  longissimus  dorsi ;  while  the 
forearms,   sterno-cleido-mastoid,  deltoid,  supra  and  infraspinatii 


DISEASES    OF    Till':    M'.KXOUS    SYSTEM 


3>^7 


usually  arc  not  ct)nccrncd.  From  the  s[)inal  i'drni  it  ditTcrs  l)y  the 
wrists  and  forearms  not  becomins;-  involved;  fibrillary  contrac- 
tions being-  almost  always  absent  in  the  affected  muscles;  and 
that  sometimes  pseudo-h}pertro])hy  of  some  nuiscles  takes 
place. 

Muscular   atrophy  of   tlie   T.andouzy-Dejerine   type      (typus 


Fig.  41 — Attitude  of  the  body  and  its  external  aspect  in  muscular  pseudo- 
hypertrophy of  the  lower  limbs  with  atrophy  of  the  muscles  of  the  spine 
(After  Duchenno;. 

facio-humero-scapularis)  begins  with  the  face.  Because  of  the 
inconsiderable  mobility  of  the  lips  the  patient  cannot  whistle, 
keeps  the  mouth  half-open,  and  the  lips  become  noticeably  thick- 
ened. Complete  closure  of  the  eye-lids  is  often  altogether  im- 
possible. Gradually  the  atroph}-  spreatls  downwards,  as  in  the 
iuvenile  form. 


388  DISEASES    OF    THE    NERVOUS    SYSTEM 

Because  of  depression  of  the  cheeks  and  dependancy  of  the 
lower  lip  the  face  assumes  the  characteristic  expression  (face 
myopathique)  which  permits  of  making  the  diagnosis  par  dis- 
tance, especially  if  there  still  exists  impossibility  of  the  complete 
closure  of  the  eye-lids. 

( d )  Paralyses  with  atrophy  and  flaccidity  of  the  muscles 
sometimes  remain  after  severe  cases  of  acute  inflammation  of  the 
spinal  membranes — leptomeningitis  spinalis  acuta.  In  such  cases 
the  development  of  paralyses  is  preceded  by  aggravated  symptoms 
of  irritation  in  the  form,  first,  of  severe  pains  in  the  spine  in- 
creasing during  movements  and  upon  pressure  over  the  spinous 
processes,  pain  in  the  limbs  (irritation  of  the  posterior  roots) 
and  general  hyperaesthesia ;  and,  second,  contracture  of  the 
muscles  of  the  spine  and  occiput  (irritation  of  the  anterior 
roots).  Later  on,  together  with  the  paralyses  there  also  develop 
anaesthesise.  The  onset  of  the  disease  is  usually  acute  with  severe 
fever. 

(e)  Weakness  of  the  legs  in  rachitic  children  manifests  it- 
self by  the  patients  beginning  to  stand  and  walk  much  later  than 
normal.  It  often  happens  that  a  rachitic  child  two  or  three  years 
old  cannot  yet  stand  on  his  legs,  even  when  supported,  while 
a  healthy  child  stands  freely  Vv'hen  ten  or  eleven  months  old.  The 
resemblance  to  spinal  paralysis  is  evidenced  by  considerable  wast- 
ing and  flabbiness  of  the  muscles,  as  well  as  by  complete  flac- 
cidity of  the  muscles  and  ligaments,  so  that  we  get  a  considerable 
mobility  of  the  hip-joints. 

In  rachitic  weakness  there  are  the  following  data : — 
(i)  Apparent  rachitic  changes  in  the  bones. 

(2)  Flabbiness  and  wasting  of  the  muscles  of  the  lower  limbs 
are  not  greater  than  in  those  of  the  arms. 

(3)  An  actual  paralysis  is  absent,  because  when  lying  in 
bed  the  patient  moves  the  legs  well,  only  being  unable  to  stand. 

(4)  The  tendon  and  cutaneous  reflexes  are  preserved. 

(5)  Indications  that  weakness  in  the  legs  had  developed 
soon  after  a  short  febrile  period  are  absent  in  the  same  history. 

As  a  cause  of  erroneous  diagnosis  of  monoplegia  due  to 
poliomyelitis  the  so-called  pseudo-paralyses  may  serve  as  ex- 
amples, among  which  we  include  cases  of  immobility  of  the  limbs 
not  because  of  disorders  of  innervation  but   simpl}-  because  of 


DISKASKS    OF     Till':    MCKVOUS    SYSTl-lM  3S9 

pain  in  the  articulation  and  in  the  l)ones.  l-"or  instance,  llic  cliiM 
refuses  to  lift  the  arm  wlien  suiTering-  with  synovitis  of  the 
shoulder-joint,  etc.  It  is  ()l)vi()us  thai  such  an  erroneous  diaii;nosis 
cannot  ohtain  in  an  older  child,  hecause  he  will  call  attention  to 
the  pain  himself  as  the  cause  of  immohility  ;  but  in  a  nursling 
this  error  is  possible  if  the  physician  takes  the  mother's  word  that 
the  child's  arm  became  at  once  paralyzed.  It  is,  of  course,  easy 
to  avoid  such  a  grave  mistake  even  where  there  is  no  noticeable 
tumor  of  the  joint,  as  there  is  always  a  severe  pain  upon  pas- 
sive movements. 

As  an  instance  of  pseudo-paralysis  which  is  especially  peculiar 
of  the  first  weeks  or  months  of  life,  one  must  point  out  epiphyseal 
syphilis  of  hereditary  origin    (Parrot's  disease). 

Underlying  this  process,  as  Prof.  Monch  showed,*  we  have 
periarteritis  syphilitica  of  the  bone-vessels,  so  that  necrosis  of 
the  endochondrous  bone  develops  which,  in  its  turn,  produces 
reaction  on  the  part  of  the  cartilage,  evidenced  by  development 
of  granulation  tissue  first  in  the  canals  of  the  preparatory  zone, 
and  then  entirely  separating  the  cartilage  from  the  diaphysis. 
Besides  this  reaction  also  appears  on  the  part  of  the  jieriosteum 
in  the  form  of  chronic  inflammation  of  the  latter.  Thus,  not  the 
epiphyses  alone  suffer,  but  the  bone  in  toto. 

During  life-time  this  process  manifests  itself  by  painful 
swelling  of  the  ends  of  the  affected  bones  and  sometimes  by  crepi- 
tation at  the  point  of  the  separated  epiphysis.  Generall\  the 
process  involves  the  long  bones  of  the  upper  extremities,  and 
either  because  of  pain  or  some  other  cause  it  is  often  accompanied 
by  complete  immobility  of  the  affected  limb  which,  being  lifted, 
falls  as  if  enervated. 

Epiphyseal  syphilis  very  readily  yields  to  mercurial  treat- 
ment, while  together  with  the  disappearance  of  the  inflammatory 
evidences  on  the  part  of  the  bone  the  apparent  paralysis  also 
passes  away. 

The  diagnosis  is  based  partly  upon  the  syphilitic  symptoms 
in  general  and  tumor  of  the  epiphysis  especially.  1\:)  mistake  this 
tumor  for  a  rachitic  one  is  impossible,  because  it  is  usuall\'  uni- 
lateral. 


'Moscow  Medical  Gazette,  187S. 


390  DISEASES    OF    THE    NERVOUS    SYSTEM 

Zappert's  case  proves,  liowever,  that  the  diagnosis  is  not 
after  all  so  easy  as  it  seems  to  be.  He  observed  a  child  fourteen 
days  of  age  having  undoubted  signs  of  inherited  syphilis  and  with 
paralysis  of  the  two  upper  limbs.  In  the  area  of  the  upper 
epiphysis  of  the  humerus  there  was  noted  an  abnormal  mobility 
and  distinct  crepitation.  Briefly,  everything  seemed  to  have  been 
in  favor  of  pseudo-syphilitic  paralysis,  yet  the  post  mortem  (the 
child  soon  died)  showed  that  the  bones  did  not  exhibit  noticeable 
changes  (crepitation  was  probably  simulated  by  the  dryness  of 
the  shoulder  joint),  and  that  paralysis  of  the  upper  limbs  was 
dependent  upon  meningitis  in  the  cervical  portion  of  the  spinal 
cord  and  degeneration  of  the  anterior  and  posterior  cervical 
roots.  The  author  thinks  that  such  mistakes  in  diagnosis  are  not 
uncommon,  therefore  he  advises  care  in  the  diagnosis  of  Parrot's 
disease  in  all  cases  of  seeming  syphilitic  false  paralysis,  when 
passive  movements  of  the  paralyzed  limbs  are  not  accompanied 
by  pain,  when  a  noticeable  tumor  of  the  epiphyses  is  absent,  or 
when,  besides  paralyses,  contractures  are  also  observed*. 

To  the  group  of  ])aralyses  accompanied  with  muscular  flac- 
cidity  and  generally  with  the  character  of  peripheral  paralysis, 
belong,  among  others  after-birth  paralyses  and  the  majority  of 
cases  of  paralysis  developing  after  acute  infectious  diseases. 

After-birth  (post-natal)  paralyses  always  aflfect  the  upper 
extremities,  and  most  often  one  side  only.  Either  the  whole 
arm  becomes  paralyzed  or  only  some  muscles  especially  innervated 
by  the  radial  nerve.  I'aralysis  due  to  applying  forceps  not  infre- 
quently involves  the  facial  nerve. 

All  these  paralyses  either  disappear  after  a  few  days  or  re- 
main permanent,  ending  with  atrophy  of  some  muscles  or  of  the 
whole   extremity. 

In  the  diagnosis  of  birth-paralysis  one  should  bear  in  mind 
false  syphilitic  paralysis  and  l^irth-fracture  of  the  bones.  Neuri- 
tis is  held  l)y  many  as  the  anatomico-pathological  essence  of  birth- 
paralysis. 

Of  paralyses  arising  after  infectious  diseases  in  childhood 
dipJitJicntic  paralysis  is  of  prime  importance,  running  usually  so 
typically  that  it  may  be  easily  recognized  even  in  case  the  patient 


*Jahrh.  f.  Kiiiderh.,  XLVL,  s.  347. 


Disi-:.\si:s  OF  tiif.  xicuxois  systiim  391 

duriiif^-  the  primary  disease  ( (li])luhoria)  was  not  under  tlie  ])liv- 
sician's  observation.  Dii)luheritic  paralysis  rarely  occurs  in  tlie 
period  of  full  development  of  the  original  disease,  while  there 
are  still  membranes  in  the  throat ;  on  the  contrary  it  is  found 
much  oftener  in  the  period  of  apparently  complete  convalescence, 
when  the  patient  leaves  his  room,  for  instance  after  three  or  four 
weeks  from  the  beginning  of  the  causative  disease. 

Paralysis  after  diphtheria  almost  aliivys  begins  with  the 
soft  palate  and  the  pharynx;  then  if  the  paralysis  extends  to 
new  regions,  which  is  far  from  happening  in  all  cases,  the  muscles 
of  visual  accommodation  are  involved  ;  in  more  severe  cases  the 
legs  become  paralyzed.  finall\\  the  arms,  and  in  rare,  but  danger- 
ous, cases  the  paral\sis  extends  to  che  muscles  of  the  larynx, 
trunk,  bladder,  diaphragm   and   face. 

The  second  characteristic  feature  of  diphtheria  paralyses  is 
their  gradual  development,  symmetrical  spreading  and  tendency 
to  disappear  after  a  few  weeks'  duration.  It  never  happens  that 
post-diphtheritic  paralysis  appears  at  once  fully  developed ;  for 
instance,  during  paralysis  of  the  soft  palate  the  patient  begins 
at  first  to  choke  at  times,  especially  when  swallowing  much  fluid, 
and  then  with  each  day  the  act  of  sw^allowing  becomes  more  and 
more  difficult  until,   finally,   it  may  become  entirely   impossible. 

The  development  of  paralyses  is  often  accompanied  by  differ- 
ent neuroses  in  the  sphere  of  the  sensory  nerv^es,  as  anaesthesia 
(insensibility  to  tickling,  pricks,  cold),  par?esthesia  (crawling  of 
ants,  numbness)   and  h\peraesthesia. 

In  the  paralysis  of  the  soft  palate  the  most  disagreeable 
symptom  is  the  difficult  deglutition,  as  the  food  and  drink  pass 
into  the  nose  and  the  larynx,  the  patient  often  choking;  the  voice 
acquires  a  nasal  twang;  the  attempt  at  blowing  out  a  candle  is 
unsuccessful,  as  the  expired  air.  finding  a  free  exit  through  the 
nose,  does  not  pass  through  the  narrow  slit  between  the  lips. 
Upon  inspecting  the  throat  the  soft  palate  is  seen  to  be  immovable 
upon  phonation ;  it  does  not  react  upon  tickling  with  a  brush 
(anaesthesia  and  loss  of  reflex  excitability). 

Recovery  may  occur  in  from  ten  to  twenty-five  days ;  very 
rarely  does  the  paralysis  disappear  in  four  or  five  days  and  may 
be  protracted  for  about  two  months. 

Paralysis  of  accommodation  is  evidenced  b\-  the  patient  los- 


392  DISEASES    OF    THE    XERVOUS    SYSTEM 

ing  the  ability  of  accommodating-  his  vision  to  near-by  objects, 
for  instance,  he  cannot  read  small  print. 

Paralyses  or  pareses  of  the  li)iibs  usually  begin  with  the 
limbs.  The  patient  complains  of  weakness  in  the  legs  which  may 
increase  until  it  is  impossible  to  stand.  The  same  gradation  of 
the  paralysis  is  also  noticed  in  the  arms ;  at  first  the  patient  com- 
plains of  weakness  and  tremor  of  the  arms  and  of  difificulty  in 
the  performance  of  small  tasks,  and  later  on  even  complete 
paralysis  may  be  developed — the  arms  hanging  lifeless.  The 
paralyzed  muscles  are  flabby,  somewhat  atrophied,  the  electrical 
excitability  considerably  declines  or  even  entirely  disappears  and 
in  the  period  of  convalescence  returns  later  than  the  voluntary 
movements. 

The  restoration  of  muscular  activity  usually  follows  the  same 
order  in  which  paralyses  had  developed,  that  is,  begins  with  the 
throat  and  pharynx,  and  progresses  very  slowly,  so  that  three 
or  four  months,  or  nvore,  are  required  for  the  complete  restora- 
tion of  strength.  If  death  comes  on,  then  it  is  either  from 
paralysis  of  the  respiratory  muscles,  or  from  pneumonia  because 
of  foreign  lx)dies  falling  into  the  bronchi,  or  from  exhaustion 
(starving),  or,  finally,  from  cardiac  paralysis  (sometimes  sud- 
denly). 

Although  diphtheritic  paralysis  is  referred  to  the  group  of 
polyneuritic  paralyses,  yet  from  primary  multiple  inflammation 
of  the  nerves  it  differs  by  quite  striking  peculiarities,  among 
which,  besides  the  characteristic  spreading  of  the  paralysis,  with 
its  beginning  at  the-  soft  palate,  may  be  included  also  that  the 
paralysis  of  the  limbs  does  not  reach  a  considerable  degree,  there 
being  only  some  weakness  but  not  a  complete  paralysis,  neither 
are  there  markedly  developed  muscular  atrophies,  nor  complete 
anjesthesia,  nor  pain  in  the  limbs  along  the  course  of  the  nerves; 
but  there  is  frequently  observed  instead  of  that  considerable 
anaesthesia  which  does  not  correspond  altogether  to  the  faintly 
developed  paralyses. 

Among  paralyses  with  muscular  tlaccidity  are  also  to  be 
included  functional  paralyses  occurring  in  chorea  and  hysteria. 

Under  the  name  of  paralytic  chorea — chorea  paralytica — we 
understand  a  common  idiopathic,  the  so-called  Sydenham's,  chorea 
running    with    the    peculiarity    that    instead   of    muscular   weak- 


DISEASES    OF    THE    NERVOUS    SVSTE>[  3^3 

ness  of  the  affected  limbs  there  arises  complete  paralysis  or,  at 
least,  paresis,  so  that  not  only  voluntary  movements,  but  even 
the  choreic  twitchings  are  checked.  The  paralysis  is  either  limit- 
ed to  one  limb,  most  often  to  the  arm,  or  it  appears  in  the  form 
of  para-  or  hemiplegia,  or  it  spreads  over  all  four  limbs  and  the 
trunk  as  well,  and  in  such  a  case  the  patient  lies  immovable  be- 
cause of  the  complete  relaxation  of  the  muscles  of  the  whole 
body,  that  is,  we  have  then  to  do  with  that  form  of  paralvtic 
chorea  which  is  known  as  lymphatic  chorea  (chorea  moUe  or  soft 
chorea  of  the  French  authors).  These  paralyses  are  characterized 
by  negative  peculiarities ;  the  cutaneous  sensibility  and  the  electri- 
cal reaction  of  the  nerves  and  muscles  are  not  impaired,  atrophy 
of  the  muscles  does  not  set  in  even  in  the  case  of  the  many 
months'  existence  of  the  paralysis ;  only  the  tendon  reflexes  are 
somewhat  lessened  or  disappear  entirely,  but  not  in  all  cases. 

As  to  the  time  of  development  of  the  paralysis  and  its  rela- 
tion to  choreic  movements,  three  kinds  of  cases  may  be  dis- 
tinguished : 

( 1 )  The  paralysis  appears  earlier  than  the  chorea  and,  after 
some  time  (two  to  six  weeks),  is  replaced  by  chorea.  JMost  often 
in  such  cases  the  paralysis  begins  in  the  arm,  being  limited  there- 
to. The  paralysis  develops  for  a  few  days,  being  accompanied 
by  no  morbid  appearances,  that  is,  there  are  neither  pain,  fever, 
facial  paralysis,  or  headache.  In  Gowers'  opinion  such  a 
paralysis  is  characteristic  to  such  a  degree  as  to  permit  the  diag- 
nosis of  beginning  chorea  with  great  certainty ;  nevertheless, 
it  is  possible  that  such  paralysis  may  be  also  of  hysterical  nature. 

(2)  Paralysis  appears  in  the  period  of  the  complete  develop- 
ment of  chorea ;  it  seldom  comes  on  suddenly,  usually  progressing 
for  several  days.  x\fter  a  few  days  it  is  again  replaced  by  chorea, 
or,  with  the  disappearance  of  the  paralysis,  convalescence  im- 
mediately sets  in. 

(3)  In  the  third  series  of  cases  the  disease  begins  with 
paralysis  which  is  limited  to  one  of  the  upper  limbs,  or  spreads 
gradually  to  all  four  extremities,  and  so  the  disease  remains  until 
the  end,  that  is,  choreic  twitchings  do  not  appear  until  the 
paralysis  is  over  and  recovery  sets  in. 

The  diagnosis  of  such  cases  is  sometimes  very  difficult ;  the 
above  mentioned  negative  signs  must  be  borne  in  mind,  as  well 


394  DISEASES    OF    THE    NERVOUS    SYSTEM 

as  the  gradual,  although  the  quite  rapid,  development  of  the 
paralysis  without  fever  and  pain,  and  especially  the  important 
fact  that,  in  the  great  majority  of  cases,  one  may  notice  in  such 
patients  sli,i::ht  tzcitchiiigs  in  the  fingers  of  both  hands  as  the 
scarcely  noticeable  manifestation  of  chorea. 

The  spreading  of  the  paralysis  in  all  these  forms  is  manifold ; 
besides  the  limbs  the  muscles  of  the  trunk  and  neck  may  also  be 
paralyzed  (the  head  hangs  down  as  in  a  corpse,  entirely  following- 
its  center  of  gravity),  and  sometimes  also  the  larynx  (aphony) 
and  even  the  bladder  and  the  rectum  are  affected. 

The  average  duration  of  the  paralysis  is  difficult  to  be  de- 
termined because  of  the  small  number  of  published  cases,  but  it 
may  be  said  to  var\-  from  two  weeks  up  to  three,  four  and  even 
six  months.  ( 

The  paralysis  is  seldom  a  complete  one.  usually  some  weak 
movements  are  possible. 

Up  to  the  present  no  single  case  of  incurable  choreic  paraly- 
sis has  been  reported,  nor  a  termination  with  atrophy  of  the 
affected  muscles,  so  that  the  prog)iosis  always  may  be  said  to  be 
favorable. 

^^tiologically  it  is  interesting  to  point  out  the  influence  of 
age  and  sex.  Like  the  common  chorea  here  also  females  are 
affected  oftener  than  males,  but  as  to  the  age  the  difference  is 
that  a  common  chorea  in  children  under  five  years  is  observed 
very  rarely  (ten  per  cent.),  while  chorea  paralytica  most  fre- 
quently occurs  at  this  age.  (Of  twelve  cases  I  am  aware  of  in 
literature  five  occurred  in  the  age  from  two  to  five  years). 

The  real  cause  (pathogenesis)  of  paralyses  in  chorea  is  un- 
known. It  is  impossible  to  explain  their  occurrence  by  chorea 
being  complicated  with  hysteria,  because  of  the  very  young  age 
of  some  patients  and  because  of  the  peculiarities  of  the  paralyses 
themselves. 

Hysterical  paralyses.  As  the  most  frequent  cause  of  paraly- 
ses of  the  legs  in  children  after  five  years,  we  would  name  verte- 
bral caries ;  and  the  second  place  of  frequency  of  their  appear- 
ance is  occupied  by  paraplegia  of  hysterical  origin,  which  occurs 
equally  often  in  males  and  females,  especially  during  the  period 
from  ten  to  fifteen  }-ears.  In  some  cases  the  patient  cannot  move 
his  legs — paraplegia   liysterica;  in  others,  being  in  bed,  he  can 


DISEASES    OF    THE    NEK\'(  )rs    SYSTEM  395 

perform  all  voluntary  movements,  hut  positively  is  unable  to 
stand  or  to  walk — astasia-ahasia  hysterica. 

As  one  of  the  most  cliaractcristic  peculiarities  of  lusterical 
paralysis  one  ma\-  generally  hold  that  it  is  uni(iuc,  not  onl\-  hecause 
it  cannot  be  ex]:)lained  by  any  anatomical  changes  in  the  central 
nervous  s_\stem.  but  even  does  not  permit  of  deciding  the  question 
as  to  the  place  of  affection,  that  is,  it  cannot  be  included  either 
among  peripheral,  or  central  paralyses.  For  example  I  refer  to 
the  following  case : — A  twelve-year-old  girl  entered  the  hospital 
from  an  infant  school  on  account  of  complete  paralysis  of  the 
left  arm.  The  paralysis  appeared  suddenly,  about  a  month  before, 
Avithout  any  ascertainable  reason.  Upon  entering  the  hospital  the 
paralysis  was  seen  to  affect  the  whole  extremity  from  the  fingers 
up  to  the  shoulder,  while  sensibility  was  also  completely  lost.  As 
monoplegia  occurring  with  anaesthesia  must  first  of  all  be  of 
peripheral  origin,  then  one  would  expect  in  our  patient  atrophy 
of  all  the  nniscles  of  the  left  hand  with  loss  of  the  electrical  re- 
action, neither  of  which  conditions  existed.  Therefore  this  paraly- 
sis could  not  be  recognized  as  a  peripheral  one.  But.  on  the 
other  hand,  it  could  not  be  regarded  as  central,  which  woul.l 
imply  the  same  being  dependent  ujxjn  a  very  circumscribed  focus 
in  the  right  hemisphere,  in  the  area  of  the  anterior  central  con- 
volution, namelv  the  point  where  the  voluntary  center  of  the  arm 
is  located.  Then  again  we  could  not  explain  ansesthesia,  and  to 
suspect  the  morbid  focus  to  be  in  some  other  location  was  im- 
possible because  of  the  monoplegic  character  of  the  paralysis. 
In  this  case,  as  in  general,  hysterical  paralyses  mostly  are  similar 
to  feigned  ones. 

Regarding  distribution  hysterical  paralyses  do  not  exhibit 
anything  peculiar,  arising  in  the  most  varied  forms,  as  mono- 
plegia, paraplegia,  hemiplegia,  paralysis  of  all  four  limbs  or  in 
the  form  of  paralvses  of  separate  regions,  for  instance,  muscles 
of  the  larynx,  bladder  and  rectum.  In  this  regard  one  may  notice 
only  that  some  muscles  very  seldom  becoine  involved,  others  com- 
paratively often.  Among  the  latter  are  included,  for  instance, 
the  laryngeal  muscles  (hysterical  aphonia,  stenotic  respiration  due 
to  paralysis  of  the  dilators  of  the  glottis,  hoarse  breathing  because 
of  paralysis  of  the  posterior  arytenoid  muscles  with  depression 
and  bending  of  the  cartilages  into  the  lumen  of  the  glottis)  :  on 


396  DISEASES    OF    THE    NERVOUS    SYSTEM 

the  contrary,  the  facial  and  the  hypoglossal  nerves  become  rarely- 
involved,  so  that  the  integrity  of  the  facial  nerve  and  of  the  tongue 
in  cases  of  hemiplegia  is  somewhat  in  favor  of  hysteria,  and  the 
presence  of  this  paralysis  almost  excludes  the  latter. 

As  to  the  dcz'clopvient  of  hysterical  paralysis  it  appears  sud- 
denly in  the  majority  of  cases,  usually  after  an  attack  of  convul- 
sions or  some  psychical  excitement,  or  after  trauma,  especially  if 
the  latter  was  accompanied  by  fright.  It  frequently  happens  that 
between  the  trauma  and  the  paralysis  a  couple  of  hours,  and  even 
days,  elapse,  such  intervals  being  quite  characteristic  of  hysterical 
paralysis.  In  other  cases  hysterical  paralysis  develops  gradually^ 
and  in  such  instances  the  paralytic  manifestations  are  not  in- 
frequently preceded  by  pain  or  appearances  of  spasm  in  the  in- 
volved limbs. 

The  degree  of  the  paralysis  is  very  manifold,  varying  front 
an  insignificant  weakness  or  rapid  tiredness  up  to  complete  paraly- 
sis, accompanied  frequently  by  contemporary  cutaneous  anaesthe- 
sia. In  some  cases  the  pa^ralysis  is  spastic,  in  others  the  muscles 
are  relaxed  (the  latter  circumstance  occurs  oftener),  but  in  any 
event  the  nutrition  of  the  muscles  and  their  electrical  reaction  are 
preserved  well  and  for  a  long  time.  A  complete  parah  sis  seldom 
occurs,  some  movements  usually  being  preserved.  It  is  especially 
peculiar  of  hysteria  that  some  muscles  act  well  in  one  respect  or 
direction,  while  other  acts  cannot  be  carried  out,  although  the  same 
muscles  seem  to  perform  them.  For  example,  in  one  of  (nir  cases^ 
which  is  described  in  the  section  on  ataxia,  an  eleven-year-old 
boy  could  neither  stand  or  walk, but  he  could  kneel  down  and  move 
upon  all  fours. 

Hysterical  paralyses  may  disappear  rapidly  under  the  in- 
fluence of  psychical  stimuli,  hypnosis  and  even  suggestion  in  the 
condition,  but  they  are  prone  to  relapses  in  which  either  the  same 
muscles  as  before  become  paralyzed,  or  a  new  group  of  muscles- 
becomes  affected. 

The  paralysis  not  infrequently  is  the  first  and  the  only  mani- 
festation of  hysteria  (the  mono-symptomatic  form  of  hysteria 
occurs  especially  often  in  childhood),  therefore  the  absence  of 
any  other  symptoms  of  hysteria  cannot  by  any  means  serve  as 
proof  that  the  given  paralysis  is  not  an  hysterical  one ;  but  if 


DISEASES    OF    THE    NERVOUS    SYSTEM  397 

Other  symptoms  of  hysteria  may  he  noted  (stigmata  hystcri^e), 
then  the  diagnosis  is,  of  course,  easier. 

The  duration  of  hysterical  paralyses  is  very  uncertain — from 
a  few  days  to  many  months  and  even  years,  therefore  the  prog- 
nosis is  serious,  although  in  childhood  the  paralyses  rarely  last 
long. 

As  to  the  differential  diagnosis  of  separate  forms  of  paralysis 
we  have  of  great  importance  in  monoplegia  the  absence  of  atrophy, 
which  negatives  the  peripheral  origin  of  the  paralysis ;  as  well 
as  the  absence  of  the  spastic  condition  of  the  muscles,  which,  to- 
gether with  the  presence  of  anaesthesia,  excludes  focal  afifection 
of  the  cerebral  cortex.  In  hemiplegia  integrity  of  the  facial  and 
hypoglossal  nerves,  anaesthesia  of  the  skin  and  absence  of  causes 
for  haemorrhage  or  embolism  will  favor  hysteria. 

Hysterical  paraplegia  may  be  readily  viewed  as  a  symptom  of 
myelitis  or  spondylitis,  especially  if  there  be  some  pain  upon  pres- 
sure over  some  of  the  spinous  processes  because  of  hypersesthesia 
of  the  skin  of  the  back.  The  moveableness  of  the  vertebral  colum.n 
upon  bending  of  the  spine  and  the  absence  of  any  allusion  to  Pott's 
protuberance  must  preserve  from  a  mistake. 

Also  important  is  the  integrity  of  the  functions  of  the  bladder 
and  rectum.  Anaesthesia  of  the  legs  in  hysterical  paraplegia  may 
be  present,  but  it  spares  the  sacrum  and  the  sexual  organs ;  while 
in  myelitis  it  extends  also  over  these  parts  and  the  trunk,  accord- 
ing to  the  situation  (height)  of  the  afifection  of  the  vertebral 
column.  The  absence  of  the  plantar  reflex  is  common  in  hysteria 
(according  to  Bizzard  it  is  even  a  constant  and  therefore  a  char- 
acteristic sign),  while  in  spondylitis  the  tickling  of  the  sole  of  the 
foot  generally  produces  a  reflex  twitching  either  in  the  whole 
leg,  or,  at  least,  in  the  toes.  The  tendon-reflexes  are,  in  hysteria, 
preserved,  and  ankle-clonus  is  usually  absent.  In  the  cases  of 
spastic  form  of  hysterical  paraplegia  there  is  observed  pseitdo- 
clomis  of  the  foot  due  to  the  twitching  of  the  triceps  surae  (gastro- 
cnemius and  soleus)  muscles,  differing  from  an  actual  clonus  by 
its  irregularity;  after  a  few  twitchings  rest  sets  in,  after  which 
new  twitchings  appear. 

Hysterical  paraplegia  appears  in  some  cases  suddenl}-,  in 
others  gradually ;  in  some  cases  a  spastic  condition  of  the  muscles 


398  DISEASES    OF    THE    NERVOUS    SYSTEM 

of  the  lower  limbs  develops,  but  the  bladder  and  rectum  almost 
never  become  involved. 

Of  peripheral  paral3'Ses  of  separate  nerves  there  most  often 
occurs  in  childhood  paralysis  of  the  facial  nerve,  which  is  readily 
recognized  by  the  deviation  of  the  face  toward  the  healthy  side ; 
the  small  branch  supplying  the  eye-lid  is  also  affected,  so  that 
the  eye  on  the  diseased  side  remains  constantly  half-open.  The 
significance  of  this  symptom  is  important,  because  the  muscles  of 
the  eye-lids  do  not  become  involved  in  the  central  paralyses  of 
the  facial  nerve. 

The  most  frequent  cause  of  the  paralysis  of  the  facial  nerve 
is,  of  course,  inflammation  of  the  middle  ear,  even  without  caries 
of  the  temporal  bone,  for  instance,  in  scarlatinal  otitis,  but  oftener 
in  chronic  otites  associated  with  affection  of  the  petrous  bone  in 
scrofulous  and  tuberculous  children.  Much  rarer  the  paralysis 
of  the  facial  ner\e  in  children  arises  under  the  inlluence  of  ex- 
posure to  cold  or  compression  of  the  nerve  by  tumors  or  scars 
around  the  ear,  or,  in  the  newly-born,  from  the  forceps. 

PARALYSIS  WITH  TENSION  OF  THE  MUSCLES,  OR  SPASTIC  PARALYSES. 

Under  the  name  of  spastic  paralysis  such  a  paralysis  is  under- 
stood in  which  the  affected  muscles  are  not  relaxed,  but,  on  the 
contrary,  are  in  the  condition  of  spasm ;  therefore  the  paralyzed 
limb  is  flexed,  passive  movements  being  performed  with  difficulty. 
The  electrical  reaction  remains  normal  for  a  long  time  and  the 
nutrition  of  the  muscles  is  good,  that  is,  atrophy  does  not  set  in. 

Spastic  paralyses  are  always  of  central  origin,  depending  thus 
either  upon  some  lesion  of  the  brain  or  wdiite  matter  of  the  spinal 
cord.  In  the  former  case  they  most  often  occur  in  the  form  of 
hemiplegia,  but  sometimes  in  the  form  of  diplegia  (affection  of 
all  four  limbs),  monoplegia  (the  arm  becomes  affected  oftener 
than  the  leg),  and  even  paraplegia.  In  the  case  of  lesion  of 
the  spinal  cord  spastic  paraplegia  most  often  occurs,  but  if  the 
process  be  localized  in  the  cervical  region,  then  also  the  arms 
become  involved.  Thus,  from  the  diffusion  of  the  paralysis  one 
cannot  always  draw  a  correct  conclusion  regarding  the  localiza- 
tion of  the  morbid  process.  In  the  case  of  a  symmetrical  paraly- 
sis the  following  circumstances  speak  in  favor  of  affection  of  the 
brain : 


DISEASES    OF    THE    NERVOUS    SYSTEM  399 

(  i)  Parescs  in  tlie  area  of  the  cerebral  nerves:  facial  and  the 
l)ranches  to  the  eye-nniscles. 

(2)  ^Mental  derangement. 

(3)  The  appearance  of  athetosis  or  chorea  or  ataxic  move- 
ments in  the  paralyzed  limbs. 

(4)  Epileptic  fits  which  not  infrequently  bear  the  real  char- 
acter of  cortical  convulsions  (begin  on  one  side  and  spread  from 
the  face  over  the  arm  and  leg,  not  being  accompanied  by  loss 
of  consciousness — rjackson's  epilepsy). 

(5)  Complete  preservation  of  sensibility. 

(6)  Unimpaired  activity  of  the  rectum  and  bladder. 

(7)  Absence  of  caries  of  the  vertebral  column  in  childhood. 

Cerebral  spastic  paralyses.  Bilateral  cerebral  infan- 
tile PARALYSIS — diplegia  spastica  iiifaiitnin — occurs  in  general 
Cjuite  rarely. 

Spastic  diplegia  of  inherited  nature  (trauma  of  the  skull 
during  labor),  known  under  the  name  of  Little's  disease,  are 
notably  peculiar.  The  symptoms  show  in  the  first  days  or  first 
months  of  life,  manifested  by  the  spastic  condition  of  the  arms 
and  legs  and  sometimes  also  of  the  muscles  of  the  trunk  and 
neck  (general  rigidity)  so  that  voluntary  movements  become 
greatly  disturbed,  despite  the  absence  of  complete  paralysis  in 
the  involved  limbs. 

Little's  disease  or  general  rigidity  differs  from  bilateral  hemi- 
plegia, first,  by  the  arms  becoming  affected  less  than  the  legs,  and, 
second,  the  spasm  prevailing  over  the  paralysis.  In  Little's 
disease  it  oftener  occurs  that  the  upper  limbs  are  abducted,  ex- 
tended and  supinated,  and  the  legs  bent  in  all  joints  and  greatly 
adducted,  while  in  bilateral  hemiplegia  the  arms  are  adducted, 
bent  and  pronated,  the  legs,  however,  extended,  the  foot  being 
somewhat  turned  inward  (pes  equino^ — varus).  In  Little's  disease 
actual  contractures  are  absent,  only  habitual  position  of  the  limbs 
being  noted,  which  position  differs  from  contractures  by  the 
patient  being  able  to  change  the  given  position,  neither  is  it  diffi- 
cult so  to  do  passively,  but  after  some  time  the  limb  assumes 
its  former  posture.  However,  between  general  rigidity  and 
bilateral  hemiplegia  there  exist  so  many  transitory  forms  that  a 
sharp  boundary  cannot  be  made.     (Fig.  42.) 

As  every  case  of  cerebral  diplegia  is  the  result  of  bilateral 


400  DISEASES    OF    THE    NERVOUS    SYSTEM 

lesion  of  the  hemispheres  it  is  obvious  that  in  diplegia  mental 
derang-ement  is  often  observed  (from  the  slightest  degree  up  to 
complete  idiocy)  with  disorder  of  the  speech.  Not  infrequently 
irregular  form  and  the  small  size  of  the  skull  are  seen,  with  im- 
perfectness  of  design  or  asymmetry  in  the  face,  strabismus,  choreic 
or  ataxic  movements  in  the  limbs,  athetosis  of  the  fingers  and 
epilepsy.  The  tendon-reflexes  are,  of  course,  always  exag- 
gerated. 

The  causes  of  bilateral  spastic  paralysis  are  in  the  majority 
of  cases  connected  with  the  process  of  labor,  constituting  the 
so-called  Little's  cetiolo^y.  Here  we  have  included  asphyxia,  diffi- 
cult labor,  premature  labor,  twin-births,  etc.  The  immediate  cause 
of  the  disease  in  such  cases  is  haemorrhage  into  the  cavity  of  the 
skull  in  the  area  of  the  central  convolutions  of  both  hemispheres. 
In  other  cases  hereditary  s}philis,  cachexia  of  the  mother,  her 
exhaustion  due  to  frequent  labors,  etc.,  are  of  value. 

Under  the  influence  of  such  conditions  hereditary  or  family 
predisposition  to  the  disease  may  appear.  In  those  rare  cases 
where  diplegia  develops  in  a  child  healthy  in  the  first  years,  the 
cause  often  remains  unknown — in  some  cases  trauma  or  some  in- 
fectious diseases  may  bear  an  setiological  relation. 

The  course  of  the  disease  varies.  In  cases  depending  upon 
Little's  aetiology  (difficult  labor,  etc.,),  if  the  haemorrhage  was 
superficial  and  did  not  produce  deep  alterations  there  may  at  first 
be  repeated  convulsions  followed  by  a  period  of  stationary  rigidity 
with  tendency  to  improvement,  so  that,  although  even  late,  the 
child  yet  learns  to  walk ;  in  grave  cases  of  congenital  diplegia,  as 
well  as  in  cases  of  diplegia  which  started  during  intrauterine  life 
of  the  child,  there  is  noticed  a  slow  but  progressive  aggravation 
evidenced  by  gradual  weakening  of  the  mental  condition  and  the 
appearance  of  epileptic  fits. 

The  post  mortem  examination  of  children  who  have  died 
many  years  after  the  beginning  of  the  disease  does  not  always 
make  it  possible  to  determine  the  primary  pathological  process 
leading  to  the  final  alterations  found  at  the  autopsy,  as  partial  or 
lobar  sclerosis  of  the  hemispheres,  porencephaly  (complete  disap- 
pearance of  some  portions  of  the  brain  so  that  a  communication 
between  the  ventricles  and  subdural  space  takes  place),  cysts  and 
scars.     The  cause  of  all  these  alterations  are  commonly  haemor- 


DISK.'.SF.S    Ol-     IIIK    XKRVOUS    SYSTEM 


40  T 


rhas^es  under  the  pia  mater  durint^-  ]al)or,  in  other  cases  emboHsni. 
thrombosis,  and  perhaps  also  inflammatory  and  primary  degen- 
erative processes.  [There  are  also  chani^es  in  die  spinal  cord  as 
seen  in  Fig.  43.]  At  any  rate,  considering  the  clinical  picture  of 
diplegia  we  cannot  make  a  pathologico-anatomical  diagnosis,  and 
the  name  itself  "cerebral  diplegia"  is  used  in  a  ])urely  clinical 
sense  for  the  designation  of  such  cases  in  ^vhich  some  affection  of 
the  motor  area  of  the  cerebral  cortex  may  be  suspected.     On  this 


Fig.  42 — Litt'e's  Disease — Position  of  the  legs  in  congenital  spastic  cerebral 
paralysis    (Shattuck). 


ground,  if  SMuptoms  of  diplegia  are  met  with  during  a  distinctly 
determinable  disease  of  the  brain,  then  such  cases  luust  not  be 
referred  to  cerebral  diplegia  or  to  bilateral  hemiplegia.  For  in- 
stance, spastic  paresis  of  the  muscles  of  all  four  limbs  may  be 
met  with  during  multiple  sclerosis,  in  tuberculosis  of  the  brain 
and  in  chronic  hydrocephalus,  so  that  all  these  dift'ercnt  pro- 
cesses we  have  to  bear  in  mind  while  making  a  ditiferential  diag- 


nosis. 


It  is  not  difficult  to  recognize  chronic  hydroce])halus  from  the 


402  DISEASES    OF    THE    NERVOUS    SYSTEM 

characteristically  enlarged  head.  Much  greater  similarity  to  cere- 
bral diplegia. may  be  presented  during  disseminated  sclerosis — 
sclerose  en  plaques  disseminees,  of  the  French  authors.  This 
disease  occurs  in  childhood  much  less  frequently  than  cerebral 
diplegia.  Besides  the  spastic  condition  of  the  muscles  this  malady 
is  characterized  by  three  cardinal  symptoms :  nystagmus  (oscilla- 
tion of  the  eye-balls),  slow,  inteiTupted   (scanning)   speech  and 


Fig.  43 — Little's  Disease — Cervical  section  of  the  spinal  cord.     Degenera- 
tion of  the  pyramidal  tract  (After  Mouratoff). 

tremor  upon  voluntary  movements ;  as  well  as  by  the  course,  the 
disease  progressing  by  exacerbations  intermingled  with  periods 
of  noticeable  amelioration  interrupted  sometimes  by  apoplectiform 
fits.  For  diplegia  there  is,  on  the  contrary,  the  stationary  course 
with  tendency  to  amelioration,  as  is  observed  in  cases  of  diplegia 
acquired  during  labor  (Little's  disease).  In  doubtful  cases  Little's 
aetiology  (asphyxia,  difficult  labor,  premature  labor)  and  the  early 
occurrence  of  the  symptoms  (during  the  first  year  of  life)  strong- 
ly speak  for  diplegia. 

Unilateral  cerebral  paralysis  or  cerebral  infantile  hemi- 
plegia— hemiplegia  cerebralis  infantum — occurs  in  two  chief 
forms : — in  some  cases  the  disease  begins  suddenly  with  violent 
fever,  vomiting  and  eclamptic  fits,  like  spinal  poliomyelitis ;  in 
other  cases  the  development  of  paralyses  and  other  evidences  oc- 


DISEASES    or    THE    X  i:K\()rS    SYSTEM  4O5 

curs  very  slowly,  and  the  onset  of  the  disease  may  be  dctennined 
only  approximately. 

Of  the  former  type  we  have  already  spoken,  namely  in  the 
section  on  s^iinal  paralysis,  to  which  this  form  is  most  similar, 
at  least  in  its  initial  period.  In  cases  with  an  inappreciable  onset 
the  picture  of  the  disease  varies,  as  in  some  instances  a  spastic 
condition  in  the  muscles  of  the  paralyzed  limbs  predominates, 
in  others  the  spasm  is  of  secondary  importance,  beinj^  replaced 
by  choreiform  movements  and  athetosis ;  in  others  again  there 
is  neither  a  spastic  condition  of  the  muscles,  nor  choreiform  move- 
ments, the  whole  disease  being-  manifested  by  unilateral  paresis 
of  the  limbs  and  lack  of  development  of  the  corresponding  arm 
and  leg.  The  paresis  does  not  afifect,  in  acute  as  well  as  in 
chronic  cases,  all  muscles  equally ;  in  the  upper  extremity  the 
muscles  innervated  by  the  radial  nerve  are  the  most  paralyzed — 
triceps,  suppinator  longus  and  extensor  digitorum,  and  likewise 
the  adductor  policis.  The  habitual  posture  of  the  arm  is  almost 
the  same  in  all  patients,  therefore  it  is  very  characteristic  of  in- 
fantile hemiplecia ;  the  shoulder  is  adducted  (pressed  to  the 
trunk),  the  forearm  flexed  at  the  elbow-joint,  the  wrist  prqnated 
and  flexed  in  the  carpo-metacarpal  joint,  the  fingers  flexed  in  the 
metacarpo-phalangeal  joints,  the  thumb  adducted.  The  leg  is  ad- 
ducted, slightly  bent  in  the  knee,  the  foot  drops  and  is  turned 
somewhat  inwards  (pes  equino-varus).     (Figs.  44  and  45.) 

The  tendon-reflexes  in  the  afl:'ected  limb  are  always  notice- 
ablely  increased,  and  sometimes  they  increase  also  in  the  healthy 
leg. 

In  the  affected  limbs,  especially  in  the  arm,  there  often 
develop  afterwards  symptoms  of  athetosis  or  chorea,  in  many  cases, 
the  patients  becoming  epileptics. 

In  distinction  from  diplegia,  unilateral  paralyses  are  much 
oftener  acquired  than  inherited  during  the  first  years  of  life. 

The  causes  remain  mostly  unknown;  not  infrequently  hemi- 
plegia arises  after  some  infectious  diseases,  especially  after  scarlet 
fever  and  whooping-cough. 

Striimpell's  attempt  at  including  acute  cases  of  hemiplegia  in 
a  separate  group  under  the  name  of  polioencephalitis  may  be 
looked  upon  as  unsuccessful,  since  in  cases  with  post  mortems 
there  has  never  been   found  an  encephalitis  limited  only  to  the 


404  DISEASES    OF    THE    NERVOUS    SYSTEM 

gray  matter  of  the  hemispheres  ;  on  the  contrary,  either  the  in- 
flammation was  found  to  also  occupy  the  white  matter,  or  the 
acute  attack  at  the  onset  depended  upon  haemorrhages  or  embol- 
ism'^. 

It  is  noteworthy  that  in  some  cases  of  seemingly  typical 
paralysis  of  Strum])ell  the  post  mortem  showed  a  solitary  tubercle 
which  evidently  remained  for  some  time  in  a  latent  condition,  and 
later  on  manifested  itself  by  the  rapid  development  of  hemiplegia 
after  a  short  period  of  convulsions. 

Sf^astic  sf^iiial  f^anilysis.  Si):istic  s])inul  ])aralysis,  or  spastic 
paraplegia,  occurs  in  two  forms;  to  one  form  belong  cases  of 
paraplegia  as  an  independent  lesion  due  to  a  primary,  isolated 
affection  (sclerosis)  of  the  lateral  spinal  columns.  This  is  the 
so-called  iciiopafhic  spastic  paralysis  characterized,  among  other 
indications.  1)\  the  <d)sence  of  any  symi)toms  on  the  part  of  the 
brain. 

In  the  second  gmu])  s])astic  ])araplegia  is  one  of  the  symptoms 
of  various  diseases  of  the  brain  and  the  spinal  cor<l  (hydro- 
cephalus chronicus.  cerebral  diplegia,  etc.).     This,  therefore,  is 


*Wollenberg  collected  forty-eight  post-mortems  of  so-called  Striimpell's 
paralysis  and  showed  that  of  twelve  cases  in  seven  there  was  softening 
due  to  embolism,  in  the  other  five — cerebral  ha?morrhages  (three  times 
because  of  a  trauma  and  twice  from  an  unknown  cause).  In  the  next 
thirteen  cases,  although  there  were  already  secondary  changes  in  the  form 
of  atrophy  and  sclerosis  of  different  portions  of  the  brain,  nevertheless 
one  could  make  out  the  nature  of  the  primary  process  from  the  presence  of 
cysts  or  apoplectic  scars;  there  was  in  no  case  primary  or  independent  in- 
flammation of  gray  matter  of  the  cortex.  In  the  third  series  of  cases  there 
was  sclerosis  in  the  area  of  the  central  convolutions,  of  an  unknown  ori- 
gin; finally,  in  the  fourth  series  there  was  a  diffuse  sclerosis  of  the  hem- 
isphere. The  conclusion  that  may  be  drawn  is  that  Striimpell's  picture  of 
the  disease  does  not  depend  upon  any  definite  disease  or  affection  of  a  cer- 
tain part  of  the  gray  matter  of  the  cortex,  as  this  symptom-complex  is  ob- 
served in  all  cases  when  there  occurs  a  sudden  destruction  of  the  integrity 
in  the  area  of  motor  tracts,  beginning  with  the  surface  of  the  brain  down 
to  the  medulla  oblongata.  The  cause  may  be  embolism,  haemorrhage, 
thrombosis  and  inflammation  (according  to  ^larie,  the  vessels  become  pri- 
marily affected  under  the  influence  of  an  unknown  infection,  and  later  on 
haemorrhage  may  also  take  place).  The  general  peculiarity  of  all  these 
processes  is  that  with  the  lapse  of  time  they  lead  to  atrophy  and  sclerosis 
of  the  hemisphere,  or  some  portions  thereof,  which  is  in  all  cases  manifest- 
ed by  the  same  and  very  characteristic  results,  known  as  spastic  infantile 
hemiplegia,  which  name,  however,  does  not  determine  the  anatomical  es- 
sence of  the  disease.  We  resort  to  this  diagnosis  therefore  in  cases  wdiich 
are  not  accessible  to  more  exact  diagnosis,  when,  for  instance,  tumor  of  the 
brain  mav  be  excluded. 


DisE.\si-:s  oi"    rill-:   xi'.Kxors  snsti'.m  40", 

known  as  syin/^loiiiatic  sf^aslic  f^aralysis.  1  lt)wcvcr.  a  .sliarj) 
l)Oun(lar\'  cannot  be  made  between  tbese  two  forms,  as  even  wlien 
pure  in  all  its  sym])tonis  spastic  spinal  paraplei^^ia  may  be  of 
cerebral  orii^in,  namely,  wliere  some  morbid  process  has  touched 
onlv  the  upper  portions  of  the  central  convolutions  where  motor 


Fig.  44 — Ccrehnil   infantile  paralysis.     Right  hemiplegia    (.Striinipeir) . 

centers  of  the  lower  limbs  are  located:  such  forms  of  dlplegice 
in  realitv  do  exist  constituting  one  of  the  varieties  of  cerebral 
dil)legice  mentioned  above.  It  is  even  very  probable  tliat  all 
cases  of  spastic  paraplegice  occurring  from  early  childhood  be- 
long to  this  category:  in  favor  of  which  the  following  circum- 
stances obtain  : 


406  DISEASES    OF    THE    NERVOUS    SYSTEM 

(i)  The  resemblance  of  the  setiolog-ical  factors  (asphyxia, 
abortive  children). 

(2)  In  spastic  paraplegia  there  occur  all  kinds  of  transition 
forms  from  a  hardly  noticeable  involvement  of  the  arms  to  the 
complete  picture  of  general  rigidity. 


Fig.  45 — Acquired  cerebral  lieniipkgia.     L.eft  hemiplegia   (Whitman). 

(3)  Cases  occur  which  formerly  exhibited  symptoms  of  cere- 
bral diplegia,  but  in  a  few  years  nnprove  to  such  an  extent  that 
only  affection  of  the  legs  remain. 

(4)  There  very  often  occur  cases  of  apparently  pure  spinal 


DISEASES   OF   '1111      M-.K\()l  S    ^^  S  II-IM 


407 


paraplegia  in  which  undoubted  cerebral  symptoms  are  observed, 
for  instance,  mental  derangement,  impairment  of  speech  and  espe- 
cially strabismus. 

In   its   pure  form    idioi'ath  ic   spinal   paralysis — paralysis 
spinalis  spastica — is  characterized  by  a  developing  paresis  or  pa- 


Fig.  46 — Spastic    parapleyiii   (Wliitmaiii. 


ralysis  with  tension  and  contractures  of  the  muscles  of  the  lower 
limbs.  Contractures  are  most  developed  in  the  triceps  cruris  (pes 
equinus)  and  in  the  adductor  muscles  of  the  femur,  and  flexors 
of  the  knee;  the  legs  are  slightly  flexed  at  the  knee-joints  and  the 
thighs  are  brought  together  so  that  they  almost  touch  each  other. 
(Fig.  46.)      If  the  patient  can   still   walk,  then  his  gait  is  very 


408  DISEASES  OF  THE   NERVOUS   SYSTEM 

typical;  he  can  step  only  on  tiptoe,  his  knees  press  each  other,  he 
moves  along"  jumping-like. 

The  development  of  the  disease  proceeds  very  slowly,  being 
usually  protracted  for  man}"  years,  starting"  from  the  first  years 
of  life. 

As  I  have  already  mentioned,  the  difference  between  the 
idiopathic  form  and  the  symptomatic  consist  in  negative  signs, 
as : 

( 1 )  Complete  absence  of  niuscular  atrophy  and  disorders  on 
the  part  of  the  sensibility  of  the  skin. 

(2)  The  normal  function  of  the  bladder  and  rectum. 

(3)  Long  preservation  of  the  normal  electrical  reaction  of 
the  nerves  and  muscles. 

(4)  The  normal  function  of  the  brain. 

Of  the  positive  symptoms  only  one  may  be  pointed  out,  name- 
ly, the  considerable  increase  of  the  tendon  reflexes,  while  the  cuta- 
neous reflexes  usually  remain  normal  ( cutaneous  reflexes  are  also 
increased  in  spondylitis  associated  with  subsequent  degeneration 
of  the  lateral  columr.s ;  besides  this,  the  skin  is  then  more  or  less 
anaesthetized,  the  bladder  and  the  rectum  i)aralyzed,  at  least  they 
are  not  controlled  by  the  will,  although  refiexly  they  can  still  per- 
form their  physiological  function  ;  the  paraplegia  develops  quicker, 
and  more  completely  than  in  spastic  paralysis,  but  the  upper 
boundary  remains  st^.ble ;  often  there  occur  reflex  pains  or  hyper- 
aesthesiae  in  the  legs  and  generally  in  regions  corresponding  to  the 
point  of  affection  of  the  posterior  roots). 

If  besides  the  lateral  columns  the  degenerative  atrophy  also 
involves  the  anterior  coruua  of  gray  matter,  resulting  in  disappear- 
ance of  the  large  ganglionic  cells,  then  simultaneously  with  paraly- 
sis and  contracture  of  the  muscles  their  atrophy  also  inevitably 
develops,  as  in  poliomyelitis,  that  is.  the  rapid  loss  of  the  electrical 
reaction  in  the  nerves  and  muscles  and  reaction  of  degeneration 
in  the  latter  during  galvanization. 

This  disease,  called  by  Charcot  sclerose  latcrale  amyo- 
trophiqite  (amyotrophic  lateral  sclerosis),  may  be  confounded  with 
idiopathic  spastic  paralysis  only  in  the  beginning  of  its  develop- 
ment, that  is,  while  symptoms  of  spasm  prevail,  but  as  soon  as 
muscular  atroph}"  sets  in,  then  the  diagnosis  may  be  readily  de- 
termined. 


DISIiASliS  UF   THli    XKRVOUS   SVSTIC.M  409 

The  further  chfferences  consist  in  tliat  in  amyotrophic  lateral 
sclerosis  the  paralysis  usually  hegins  in  the  arms,  then  the  process 
spreads  downwards  (paralysis  of  the  lej^s)  and  upwards  to  the 
medulla   oblong-ata,   which    is   indicated   1)\'    symptoms   of   bulbar 


Fig.   47 — Potfs    Disease  (Whitinain. 

paralysis  in  the  form  of  paralysis  and  atrophy  of  the  lips  and 
tongue,  difficult  deg-lutition  and  respiration. 

There  is  some  difference  also  in  the  age  of  patients  ;  idiopathic 
spastic  paralysis  usually  begins  in  the  early  months  of  life,  while 
amyotrophic  sclerosis  almost  never  earlier  than  ten  years. 


4IO 


DISEASES  OF   THE   NERVOUS   SYSTEM 


From  progressive  ninsciihr  atrophy  amyotrophic  sclerosis 
differs  by  the  initial  paralysis  and  muscular  rigidity.  Dift'erent 
forms  of  progressive  muscular  atrophy  in  children  occur  consider- 
ably oftener  than  am}-otrophic  sclerosis. 

(Jf  special  importance  in  childhood,  according  to  frequenc)-  of 
appearance,  is  symptomatic  s])la?tic  paraplegia  due  to  compression 


i 

1 

J 

^^^^^k^^ 

J 

Fig.  48. — Pott's  disease  of  liie    middle  dorsal   I'e.nion   (Whitman). 


of  the  spinal  cord  during  vertebral  caries,  that  is,  <luring  so-called 
Pott's  disease— Malum  Potti,  s.  osteomyelitis  spinalis,  s.  osteo. 
granulosa.  Pott's  disease  is  nothing  but  fungous  or  tuberculous 
inflammation  of  one  or  several  vertebras  with  the  tendency  in  one 
case  to  dry  caries,  in  another  to  suppuration.  Granulations  ap- 
pear at  first  on  the  anterior  surface  of  the  vertebral  lx>dy,  then 
spreading  to  the  depth  of  the  bone.     The  vertebra  thus  grows 


niSKASES    OF     iME    XKRXOl'S    SVSTKM  4[I 

soft  and,  yieldins;-  to  the  pressure  of  the  upper  portion  of  the  Ixxly 
becomes  crushed,  and  the  vertebral  column  bent  in  such  a  vvav 
that  the  spinous  process  of  the  diseased  vertebra  forms  the  most 
prominent  point  of  the  aui^ular  curvature.  (Figs.  47  and  48.) 
The  latter  therefore  constitutes  the  most  certain  sign  in  the  dis- 
tinctiiMi  of  iiaraj)lcgia  duo  to  compression  of  the  spinal  cord  be- 


Fig.  49 — Rachitic  kyphosis   (Whitman). 

cause  of  Pott's  disease  from  any  other  paraplegia,  and,  as  this  sign 
is  a  very  striking  one.  then  as  soon  as  it  has  made  itself  evident 
there  is  no  further  difficulty  as  to  the  cause  of  the  paraplegia.  It 
is  not  easy  to  confound  this  protuberance  with  vertebral  ciu'vattu'e 
(Fig.  49),  because  the  latter  is  always  arch-like,  and  is  necessarily 
accompanied  by  rachitic  changes  of  the  chest  wall,  and  free  mova- 
bility  of  the  back. 

Concerning  the  condition  of  the  paralyzed  muscles  in  Pott's 


412  DISEASES    OF    THE    NERVOUS    SYSTEM 

disease,  although  1  have  placed  this  paraplegia  in  the  class  of 
spastic  paralyses,  yet  by  this  1  do  not  mean  to  say  that  the 
paralyzed  muscles  are  in  a  condition  of  tension.  Of  great  im- 
portance here  is  the  ])eriod  of  the  disease  and  the  part  affected. 
Spastic  svmptoms  appear  comi)aratively  late  when  subsequent 
descending  degeneration  of  the  lateral  column  has  sufficient  time 
to  set  in,  and  when  the  process  occupies  either  the  dorsal  or  the 
cervical  ])ortion  of  the  vertebral  column  ;  while  the  afifection  of 
the  lumbar  portion  may  not  be  accompanied  by  a  spastic  condition 
of  the  muscles. 

Paraplegia  dependent  r.ot  so  much  upon  myelitis  as  upon 
compression  of  the  spinal  cord  is,  among  other  signs,  characterized 
by  the  ability  of  movement  sutTering  considerably  more  than  the 
sensibility,  the  cutaneous  reflexes  being  considerably  increased, 
and  by  the  fact  that  the  paralysis  of  the  legs  may  suddenly  dis- 
appear after  extension  of  the  vertebral  column  by  the  applied 
jacket.  The  nutrition  of  the  muscles  and  their  electrical  reaction 
remain  normal  for  a  long  time. 

Tlic  tendon  and  ciifoneous  reflexes  arc  c\va!^i:;cratcd  from  tlie 
z'cry  bes'inniiia. 

,\ngular  curvature  in  the  dorsal  portion  of  the  vertebral 
column  appears  earlier  and  is  more  pronounced  than  in  the  lumbar 
portions  since  normally  the  lunil)ar  portion  a])pears  concave.  For 
this  reason  it  often  happens  that  one  of  the  lumbar  vertebrre  may 
be  already  considerably  destroyed,  deformity  being  still  absent,, 
and  the  effect  is  limited,  perhaps,  only  to  the  physiological  lordosis 
of  the  lumbar  region  becoming  even  or  b_\'  the  protuberance  of 
the   corresponding   spinous   process  being  hardly   noticeable. 

In  some  cases  one  succeeds  in  i)alpating  a  tumor  due  to  a 
burrowing  abscess  in  the  abdomen  over  Poupart's  ligament,  and 
thus  may  recognize  vertebral  caries,  notwithstanding  the  absence 
of  the  angular  deformity  which  has  not  had  time  to  develop.  Such 
abscesses  are  indolent  and  often  not  accompanied  even  by  the 
least  hindrance  in  the  movements  of  the  thigh,  in  short,  they 
run  latentlv  and  are  detected  by  the  physician  only  upon  the  ob- 
jective examination  of  the  abdomen,  by  palpating.  In  doubtful 
cases,  for  instance,  in  small  crying  children,  chloroform  must  be 
resorted  to  for  the  purpose  of  diagnosis. 

It   is   more   difficult   to   recognize    Pott's   disease   in   the   be- 


DISEASES  or  Till':  xi:R\(trs  snsi'i:.\i  413 

ginnins:  of  its  development.  It  usually  starts  with  pain  in  the 
back.  This  pain  partly  cle])en(ls  u])on  osteomyelitis  itself,  partlv. 
however,  upon  the  extension  of  the  intlanimalory  process  over  the 
spinal  membranes  and  the  posterior  roots.  It  is  characteri/.ed 
by  increasing"  upon  pressure  over  the  spinous  processes  of  the 
diseased  vertebrjE  and  especial!)  upon  boKliiii:^  the  sf^inc,  as  well 
as  upon  passins:  a  hot  spong'e  over  the  vertebral  column,  or  upon 
applying-  the  cathode  to  the  afifected  place.  Because  of  painful 
flexion  of  the  si)ine  the  patient  cries,  when  walking  he  gives  the 
trunk  an  immobile,  extended  posture,  and.  when  he  has  to  lift 
somethino-  from  the  floor  he  can  do  so  only  by  squatting  di^wn. 
that  is,  he  flexes  the  knees,  but  the  spine  is  kept  erect.  If  also  the 
posterior  roots  are  involved  in  the  inflammation,  then  besides  the 
local  pain  in  the  spine  there  also  appears  reflex  i)ain  in  the  area 
of  distribution  of  nerves  arising  in  the  diseased  region.  These 
eccentric  pains  are  observed  most  often  in  the  legs  (in  the  case 
of  aft'ection  of  the  lumbar  portion  of  the  vertebral  column)  and  in 
the  abdomen  (in  case  the  dorsal  iX)rtion  is  involved)  extremeh- 
troubling  the  oatient.  Thev  usuallv  occur  ueriodically  in  the 
form  of  neuralgiae  (or  enteralgise),  sometimes  continuing  for 
several  consecutive  hours  each  day.  This  pain  may  appear  dur- 
ing the  earliest  period  of  the  disease,  long  before  the  formation  of 
any  deformity. 

As  the  cause  of  spondylitis  is  always  scrofulosis  or  tuber- 
culosis (trauma,  however,  which  is  usually  mentioned  in  the  his- 
tory, is  only  an  accidental  cause),  then  for  the  correct  estimation 
of  the  initial  pain  it  is  important  to  give  attention  to  the  patient's 
habitus ;  children  disposed  to  spondylitis  often  appear  anaemic, 
with  flabbv  muscles,  swollen  lymphatic  glands,  chronic  eczema, 
scars  due  to  an  old  caries,  etc. 

Even  in  the  initial  period  of  spondylitis  the  child  does  not 
walk  willingly  and  does  not  run  about,  neither  does  he  jump: 
when  sitting  he  likes  to  support  his  head  with  the  hands,  and 
when  Iving  he  sometimes  assumes  a  posture  on  the  side  or,  which 
is  more  characteristic,  on  the  abdomen  if  the  spine  is  very  sensitive 
to  pressure. 

Sometimes  inflammation  of  the  vertebrae  begins  with  fever. 
the  true  nature  of  which  remains  for  a  long  time  unrecognized. 


414 


DISEASES    OF    THE    NERVOUS    SYSTEM 


The  temperature,  of  remitting  type,  with  morning  falls  to  38  de- 
grees C.  (100.4  degrees  F.)  plus,  and  the  evening  elevations  up 
to  39  degrees  C.  (102.2  degrees  F.)  during  the  first  days,  in  the 
absence  of  any  local  symptoms  on  the  part  of  the  spine,  as  well 
as  of  other  organs,  may  simulate  typhoid  fever,  until  backache 
appears   which   will   disclose  the   condition.      In   a   nursling   the 


Fig.   50 — Cervical  disease  and  characteristic  attitude   (Whitman). 

backache  is  oftentimes  indicated  by  screaming  every  time  it  is 
taken  from  the  bed. 

Backache  increasing  upon  pressure  over  the  spinous  pro- 
cesses of  all,  or  only  of  some,  vertebrae  may  occur  in  nervous  chil- 
dren because  of  hypercssthesia  of  the  skin  of  the  back,  but  it  is 
not  difficult  to  distinguish  this  condition  from  spondylitis,  first, 
because  bending  of  the  spine  is  not  painful  in  hypersesthesia  of 
the  skin.  and.  second,  because  the  pain  increases  even  upon  the 


DISEASliS    OF    TII1£    NKRVOUS    SYSTEM  415 

slightest  touch,  ^vhilc  in  spondylitis  it  a])pcars  only  upon  heavier 
pressure. 

Some  peculiarities  regarding  the  diagnosis  are  presented  by 
cervical  spondylitis.  Even  in  the  oldest  cases  there  is  absent  an 
angular  distortion,  and  if  a  curvature  should  appear  it  is  in  the 
form  of  an  arch-like  kyphosis.  Completely  developed  cases  of 
cervical  spondylitis  are  also  characterized  by  infiltration  of  the 
soft  parts  around  the  affected  vertebne,  so  that  one  may  palpate 
and  see  with  the  eye  a  more  or  less  solid  tumor  on  both  sides 
of  the  spinous  processes  of  the  involved  vertebrae.  (Such  tumors 
also  develop,  of  course,  around  the  dorsal  vertebrae,  but  remain 
obscure  because  of  the  thick  sheath  of  muscles).  In  this  period 
spondylitis  can  lead  to  the  formation  of  a  retro-pharyngeal  abscess 
on  the  posterior  wall  of  the  fauces,  which  may  be  easily  palpated 
by  the  finger  introduced  into  the  mouth.  It  will  be  recognized  as 
a  soft  elastic  tumor  which  if  of  considerable  size  will  act  as  a 
serious  hindrance  to  deglutition  and  respiration. 

Reflex  pain  in  cervical  spondylitis  is  felt  either  in  the  head 
(especially  in  the  occiput),  if  the  upper  vertebrae  be  affected,  or 
in  the  arms  in  case  the  lower  vertebrae  be  involved. 

Appearances  of  spastic  paralysis  together  with  complete,  or 
oftener  incomplete,  anaesthesia  occur  not  only  in  the  legs,  but  also 
in  the  arms;  because  of  the  paralysis  of  the  pectoral  muscles  respira- 
tion is  performed  almost  exclusively  by  the  diaphragm. 

In  affection  of  the  two  upper  vertebrae  the  external  tumor  is 
usually  absent,  but  the  lesion  is  easily  discovered,  because  the 
lateral  movements  of  the  head  become  entirely  impossible,  while 
bending  of  the  head  forwards  is  possible  to  some  extent.  It  is 
also  quite  characteristic  for  this  spondylitis  that,  upon  changing 
the  sitting  posture  for  a  horizontal  one  the  patient  necessarily 
sustains  his  head,  in  this  or  that  way,  with  his  hands,  for  instance 
by  putting  them  under  the  occiput  or  grasping  at  the  hair.     (Fig. 

50.) 

With  such  a  localization  of  the  process  the  patient  can 
suddenly  die  because  of  rupture  of  the  odontoid  process  of  the 
second  vertebra,  which  then  may  become  impinged  upon  the  spinal 
cord. 

In  the  beginning  of  its  appearance  cervical  spondylitis  is 
characterized  bv  pain  and  immobility  of  ihe  neck  and  contracture 


4l6  DISEASES    OF    THE    NERVOUS    SYSTEM 

of  the  neck-muscles,  usually  the  posterior  (Vig.  51),  but  some- 
times only  of  the  lateral,  the  head  then  bending-  to  the  shoulder — 
torticollis.     (Fig.  52.) 

In  this  stage  cervical  spondylitis  may  be  confused  with  vari- 
ous processes  leading  to  contracture  of  the  neck  (see  torticollis), 


Fig.   51 — Disease   of   the   upper   dorsa:    region    (Whitman). 

but  the  diagnosis  is  distinguished  by  all  these  processes  having 
an  acute  course  and  the  vertebrae  being  painless  upon  pressure. 
This  last  sign  also  occurs  only  in  another  form  of  curvature  of 
the  neck,  in  inflammation  of  the  synovial  membrane  between 
the  oblique  processes — synovitis  articnlaris  proc.  obliq.,  s.  syno- 
vitis vertehralis — which  disease  is  mostly  peculiar  to  childhood. 


i)isi:.\sKs  oi-   Till-:  xkkvous  system 


4'7 


Besides  the  acute  course  with  rapid  termination  in  recovery, 
vertebral  synovitis  dififers  further  from  spondyhtis  by  pressure 
producino-  pain  only  on  one  side,  and  somewhat  farther  from  the 
spinous  processes,  while  in  spondylitis  the  pain  is  bilateral  and 
severest  in  the  re^ci^ion  of  the  spinons  process  itself. 

Wherever  in  the  vertebral  cohnnn  the  s])ondylitis  may  be,  it 
is  always  of  slow  course,  and  if  it  does  not  lead  to  death  because 
of  pyaemia  due  to  the  formation  of  burrowing  abscesses,  or  gen- 
eral tuberculosis,  it  takes  from  several  months  to  two  vears  before 


Fig.  52 — Cervical  disease  with  abscess   (Whitman). 

there  will  occur  complete  recovery  with  the  formation  of  ankylo- 
sis of  the  vertebrae  at  the  place  of  destruction. 

.  [Pott's  disease  must  be  also  diiTerentiated  from  the  sacro- 
iliac disease  in  children.  In  this  connection  R.  C.  Dun  says : 
"From  early  lumbar  spinal  disease  without  deforniit\,  the  difli- 
culty  of  diagnosis  may  be  great,    \\nicre  movements  of  the  trunk 


4l8  DISEASES    OF    THE    ^^ERVOUS    SYSTEM 

give  pain,  and  where  irritation  of  the  psoas  prevents  movement 
of  the  spine  in  sacro-iHac  disease,  the  greatest  care  in  differentia- 
tion must  be  employed.  Fixation  of  the  pelvis  has  to  be  resorted 
to,  when  it  will  be  found  that  careful  and  gradual  flexion  of  the 
spine  forwards  and  towards  the  affected  side,  so  as  to  relax  the 
psoas  muscle,  will  allow  of  a  wide  range  of  painless  movement 
in  this  direction.  Should  this  free  movement  be  possible,  and 
swelling  be  present  over  the  sacro-iliac  joint,  while  point  pres- 
sure over  the  articulation  and  separation  of  the  iliac  spines  pro- 
duce pain,  then  spinal  disease  may  be  excluded."* — Earle.] 

The  more  advanced  the  process  of  recovery  the  less  the  pain 
in  the  area  of  the  aft'ected  vertebra  upon  pressure  over  it,  as 
well  as  upon  movements  of  the  trunk ;  at  last  paraplegia  also 
disappears,  but  the  angular  curvature  remains,  of  course,  during 
the  whole  life.  Complete  recovery,  that  is,  formation  of  an  en- 
tirely solid  ankylosis,  is  concluded  from  the  fact  that  the  patient 
not  only  does  not  complain  of  pain  in  the  spine,  but  also  moves 
freely. 

It  is  quite  certain  that  in  some  cases  spastic  paralysis  of 
the  lower  limbs  may  be  purely  of  hysterical  origin.  One  must 
first  of  all  think  of  hysteria  in  those  cases  wherein  spastic  para- 
plegia appears  as  an  acute  disease,  as,  for  instance,  in  the  follow- 
ing case : — 

M.,  a  girl  ten  years  of  age,  entered  the  hospital  on  February 
I,  1895,  on  account  of  paralysis  of  the  legs.  The  patient  was  an 
orphan,  so  that  a  satisfactory  history  could  not  be  obtained. 

The  present  disease  started  two  weeks  before.  The  patient 
awoke  at  night  with  severe  pain  in  the  legs  and  the  spine ;  toward 
morning  the  pain  subsided,  but  the  gait  became  difficult  and  un- 
steady; three  days  later,  the  patient  ceased  walking-  altogether 
and  could  not  even  sit  up.  About  two  days  after  that  incon- 
tinence of  urine  and  faeces  appeared ;  at  times  since  this  date  pains 
appeared  in  the  lower  limbs.  During  all  the  period  there  was 
neither  fever,  vomiting,  or  headache. 

The  present  status: — The  patient  is  of  fair  complexion  and 
nutrition ;  the  mucous  membranes  and  skin  of  normal  tint ;  in- 
clination to  constipation ;  the  abdomen  somewhat  expanded ;  the 


^Liverpool  Medico-Chirurgical  Journal,  June,  1903,  p.  207. 


DisEASi:s  OF  'i"!ii-:  NKRVou.s  svsTl•:^[  419 

lung's  and  heart  normal.  The  consciousness  and  speech  normal, 
likewise  the  superior  sensory  organs;  the  cranial  nerves  not  affect- 
ed. In  the  up])er  limhs  treninr  upon  slight  movements,  so  that 
feeding-  is  very  difficult,  but  the  strength  of  the  arms  is  normal. 

In  the  legs  there  are  appearances  of  markedly  developed 
spastic  paralysis  with  exaggeration  of  tendon-reflexes  ;  an  actual 
foot-clonus  is  absent,  but  if,  when  the  patient  is  in  recumbent 
posture,  the  extended  leg  be  lifted,  then  there  immediately  appears 
violent  twitching  in  the  leg-muscles,  which  lasts  quite  long,  de- 
creasing or  increasing.  The  plantar  reflex  is  absent  upon  mild 
tickling,  but  ap])ears  upon  rough  irritation  of  the  foot-sole.  Pas- 
sive movements  of  the  leg  are  interfered  with  in  all  articulations 
because  of  muscular  rigidity.  A  marked  anaesthesia  in  the  thighs 
and  the  lower  portion  of  the  abdomen  and  in  the  face.  The  electri- 
cal excitabilitv  is  preserved;  trophic  disturbances  are  absent; 
sphincters  normal. 

A  diagnosis  of  the  hysterical  form  of  spastic  paraplegia  was 
in  this  case  not  difficult ;  the  acute  onset  of  spastic  symptoms  ex- 
cluded any  possibility  of  the  so-called  idiopathic  spastic  paralysis, 
which  depends,  it  is  thought,  upon  primary  degeneration  of  the 
lateral  columns  of  the  spinal  cord.  Spondylitis  could  not  be  ad- 
mitted either,  being  contradicted  by  the  acute  development  of 
the  disease  and  by  the  complete  movability  and  painlessness  of 
the  spine.  Transverse  myelitis  from  any  cause  could  also  be  ex- 
cluded by  the  integrity  of  the  pelvic  organs  and  limitations  of 
anaesthesia.  Briefly,  the  sudden  onset  of  the  rigid  paralysis,  ex- 
cluding diseases  of  the  brain  and  spinal  cord,  decidedly  favored 
hysteria.  This  diagnosis  was  confirmed  by  the  weak  plantar 
reflex,  peculiar  clonus  of  the  foot  and  results  of  treatment.  The 
first  ten  days  antispasmin  was  given,  but  without  results;  then 
suggestion  was  undertaken  (without  causing  sleep),  to  the  efTect 
that  the  paralysis  would  be  over  within  five  days  (February  i8th) 
while  for  the  purpose  of  acting  upon  the  psychical  condition  a 
slight  faradic  current  was  administered  and  antipyrin  was  given 
internally.  Some  movability  of  the  legs  appeared  on  the  sixteenth 
of  Februar}',  and  on  the  eighteenth  of  that  month  it  was  noted  in 
the  history : — "The  movements  in  the  legs  are  free,  the  patient 
can  lift  the  leg  to  an  extended  posture,  mox'cs  the  ttses,  can  sit  tip 


420  DISEASES    OF    THE    NERVOUS    SYSTEM 

herself  and  can   even   walk."     Within  one  month   the   girl    was 
discharged  as  perfectly  well. 

ATAXIA. 

Incoordination  of  movements  known  as  ataxia  occurs  in 
childhood  in  acute  and  chronic  forms ;  the  latter  is  more  uncom- 
mon. Ataxia  is  manifested  either  hy  an  unsteady  gait  with  wide- 
ly-spread legs,  or  h}-  the  complete  inahility  to  stand  or  walk. 
Upon  being  put  upon  his  legs  the  patient  either  totters,  or  abruptly 
falls.  It  is  especially  difficult  for  the  patient  to  stand  with  closed 
eyes  (Romberg's  symptom).  When  lying  in  bed  exact  move- 
ments are  impossible,  the  patient  cannot,  for  instance,  put  the 
heel  of  one  foot  over  the  knee  of  the  other  leg ;  cannot  touch  with- 
out mistake  the  tip  of  the  nose  with  his  forefinger,  etc. 

Acute  ataxia,  that  is,  such  incoordination  as  develops  within 
a  short  period  (from  a  few-  days  up  to  several  weeks)  occurs, 
in  general,  quite  rarely  and  especially  so  in  childhood. 

Acute  ataxia  is,  of  course,  not  a  disease,  but  only  a  symptom 
which  may  be  met  with  in  different  diseases  of  the  nervous  sys- 
tem, central  and  peripheral. 

Ataxia  makes  itself  evident  especially  in  the  lower  limbs, 
leading  in  severe  cases  to  incai)al)ility  of  walking  and  even  stand- 
ing. Such  cases  are  described  under  various  names,  of  which  the 
most  common  is  false  locomotor  ataxia — pseudo-tabes,  and  peri- 
pheral locomotor  ataxia — tabes  peripherica  s.  nervo-tabes  peri- 
pherica.  The  latter  name  is  due  to  the  great  majority  of  cases 
of  false  tabes  having  been  proven  to  be  the  result  of  neuritis. 

.Etiological ly  all  cases  of  acute  ataxia  nia\'  be  divided  into 
four  groups : — 

(i)  Toxic  form.  This  form  is  the  most  frequent  in  adults, 
but  in  childhood  it  occurs  very  rarely,  as  children  seldom  have 
the  opportunity  of  being  poisoned  with  such  substances  as  pro- 
duce this  variety.  Of  prime  importance  here  is  alcohol,  then 
arsenic,  lead  and  mercury.  Acute  ataxia  develops  in  these  cases 
because  of  chronic  parenchymatous  nephritis. 

More  peculiar  to  childhood  is  the  second  form  of  false  tabes, 
due  to  various  acute  infectious  diseases ;  this  is  the 

(2)  Infectious  form.  Of  all  acute  infectious  diseases  in  this 
connection  the  first  position  is  occupied  by  diphtheria,  which  pro- 
duces characteristic  paralyses  and   sometimes  also  acute  ataxia. 


i)isi:.\si;s  OK  thf.  xiiuvors  svstkm  42: 

tlirou^h  the  allectioii  of  ])eriphoral  nerves  as  well  as  ui  the  eenlral 
nervous  system.  The  overwhelmiiif^'  majority  of  cases  of  acute 
ataxia  in  children  helon^s  to  this  class  of  ataxi;e  of  diphtheritic 
orif^in.  lUu  hesides  di])htheria,  ataxia  may  also  he  the  result  of 
tyjihoid,  small-jiox,  scarlet  fever,  dysentery  and  sy])hilis  in  the 
secondar}-  period.  In  the  o])inion  of  some  neurologists  we  have 
to  i\o  in  all  these  cases  with  neurites,  but,  as  a  matter  of  fact,  the 
symptoms  (^f  these  neurites  are  in  some  instances  too  obscure,  so 
that  the  degree  of  ataxia  often  ckx?s  not  corresixind  at  all  to  the 
degree  of  affection  of  the  motor  ov  sensory  nerve  fibers,  that  is. 
considerable  ataxia  occurs  together  with  insignificant  disorders 
of  sensibility  and  with  slight  pareses.  According  to  Mouratofif* 
**A  polineuritic  ataxia  may  occur  with  exaggerated  reflexes,  al- 
most with  normal  sensibility,  and  even  without  any  other  symi)- 
toms  of  neuritis."  briefly,  as  a  pure  ataxia,  but  the  pathogenesis 
of  ataxia  remains  in  such  cases  very  uncertain  and  then  a  sus- 
picion arises  as  to  the  central  origin  of  the  condition.  ( )ne  such 
case  is  given  in  the  group  of  ataxi?e  of  central  origin,  where  this 
subject  will  be  spoken  of  more  in  detail. 

(3)  The  third  group  is  composed  of  cases  of  ataxia  which 
have  the  character  of  a  neurosis.  In  such  the  patient  does  not 
exhibit  any  symptoms  of  organic  changes  in  the  peripheral  nerves 
or  in  the  central  nervous  system ;  and  at  the  same  time  the  rapid 
issue  in  recovery  under  the  influence  of  some  form  of  treat- 
ment, or  i)lainl\-  imder  the  influence  of  suggestion,  does  not  cor- 
respond to  the  proposition  of  the  neuritic  origin  of  the  aff'ec- 
tion. 

To  this  section  Ijelongs  first  of  all  ataxia  hysterica  in  the  form 
of  astasia  j)id  abasia,  that  is,  inability  to  stand  or  walk,  the 
strength  of  the  lower  extremities  being  preserved,  as  they  can 
perfectly  well  be  moved  by  the  patient  when  lying  in  bed  without 
the  slightest  signs  of  ataxia.  The  sensibility  is  entirel\  normal, 
as  well  as  the  reflexes  from  the  skin  and  tendons.  Of  other  nega- 
tive symptoms  one  may  note  absence  of  spasticity  and  atrophy 
of  the  muscles,  pains  and  dizziness  ;  indeed  the  patient  exhibits 
no  other  svmptom  aside  from  the  impossibility  of  standing  and 
walking. 


*Lccturcs  oil  Xcrz'OHs  Diseases  of  Childhood   (Russian).   1898.   p.    120. 
Moscow. 


422  DISEASES    OF    THE    NERVOUS    SYSTEM 

This  form  most  often  occurs  in  the  period  of  Hfe  between 
ten  and  fifteen  years  (Govseyeff  collected  fifty-four  cases  of 
astasia,  of  which  twenty-four  cases  were  in  age  from  six  to  fifteen 
years,  that  is,  forty-two  per  cent).  In  view  of  the  importance 
of  such  cases  in  relation  to  the  question  of  diagnosis  as  well  as 
therapeusis  we  present  here  a  short  history  of  one  of  our  clinical 
patients : — 

K.  L.,  male,  aged  eleven  years,  entered  the  clinic  on  January 
19,  1895,  on  account  of  paralysis  of  the  legs.  He  comes  from 
a  tuberculous  .familv,  the  father  is  an  alcohol  drinker,  the  mother 
suffers  from  migraine ;  the  grandfather  on  the  mother's  side  died 
during  an  attack  of  delirium  tremens.  Previously  always  in  good 
health  the  boy,  K.,  became  sick  with  paralysis  under  the  following 
circumstances ;  in  November,  1894,  he  was  violently  frightened 
at  school  by  the  threat  of  the  teacher  and  began  to  shiver ;  the 
teacher  ordered  him  to  leave  the  class,  when  a  fit  happened  to 
him  with  loss  of  consciousness,  and  he  awoke  at  home  on  the 
following  day.  From  that  time  the  patient  could  neither  walk, 
or  stand,  but  was  evidently  in  all  other  regards  entire!)-  well.  On 
December  5th,  in  the  evening,  the  patient  cried  out  and  at  once 
fell  into  a  state  of  unconsciousness,  while  slight  tvvitchings  were 
noticed  in  the  shoulders  and  in  the  legs.  The  condition  lasted 
about  an  hour  before  the  patient  recovered  his  senses.  After  that 
for  several  days  in  succession,  in  the  evenings  just  before  bed- 
time, slight  attacks  happened  to  him,  but  without  screaming,  in 
which  the  patient  would  look  around  amazedly,  and  would  not 
answer  questions.  The  last  fit,  with  screaming,  loss  of  conscious- 
ness and  visual  hallucinations  occurred  on  December  i8th,  also 
in  the  evening,  having  lasted  three-quarters  of  an  hour,  after 
which  there  were  no  further  attacks,  and  the  patient  was  unable 
to  walk  or  to  stand  just  as  before. 

The  present  condition.  The  patient  is  of  good  complexion 
and  nutrition ;  the  skin  and  the  mucous  membranes  of  normal 
tint.  Organs  of  digestion,  respiration,  circulation  and  of  the 
genito-urinary  system  do  not  exhibit  anything  abnormal ;  the 
vertebral  column  painless  upon  pressure  and  bends  freely.  On 
the  part  of  the  nervous  system  the  anomalies  consist  in  that  the 
patient  is  unable  to  walk  or  stand ;  upon  attempts  to  put  him 
on  his  feet  the  legs  bend  at  the  knees  and  hip-joints  as  if  entirely 


DisiiASi.s  ;)F  'jiiii  .\i':i<\()i's  s^•s^l•;.\l  423 

paralyzt'd,  yet  while  Ixiiii^  in  l)c(l  the  patienl  perforins  with  con- 
siderable force  varied  movements  with  both  legs;  besides  this,  he 
can  kneel  and  even  move  on  all  fours.  The  muscles  of  the  lower 
limbs  are  not  atrophied,  the  electrical  reaction  and  tendon-reflexes 
are  preserved,  anaesthesia  and  hypenesthesia  absent,  as  well  as  a 
spastic  state  of  the  muscles.    The  pelvic  organs  unaffected. 

The  diagnosis  of  hysterical  astasia-abasia  was  based  espe- 
cially on  the  impossibility  of  explaining  the  symptoms  by  any 
affection  of  the  spinal  cord  (integrity  of  the  vertebral  column, 
absence  of  anesthesia  and  sphincter  paralysis)  and  on  the  fact 
that  movements  of  the  legs  were  performed  with  full  strength, 
while  only  standing  aufl  walking  were  impossible. 

The  diagnosis  was  amjjly  confirmed  by  the  results  of  the  treat- 
ment. The  patient  was  told  that  if  the  pain  should  be  weaker  to- 
day after  using  the  galvanic  current  than  to-morrow,  then  he  will 
positively  recover  on  the  fifth  day  (Saturday).  Of  course, 
we  employed  a  stronger  current  the  next  day.  In  the  early  morn- 
ing, about  five  o'clock,  Saturday,  the  patient  awoke  and  joyfully 
asked  the  nurse  for  stockings  as  he  wanted  to  walk.  He  was 
dressed  and  immediately  walked,  after  a  two  months'  stay  in 
bed.  He  was  in  the  clinic  seventeen  days  and  then  discharged 
healthy. 

To  the  same  group  of  ataxia  as  a  neurosis  belong  cases  of 
ataxia  of  reflex  origin.  These  forms  are  especially  interesting 
in  purely  ])ractical  regards,  as  the  correct  diagnosis  makes  such 
an  ataxia  readily  accessible  to  the  influence  of  setiological  therapy, 
which  usually  leads  to  quick  recovery.  From  a  consideration  of 
the  literature  one  would  think  that  in  the  aetiology  of  reflex  ataxia 
a  great  role  is  played  by  irritation  of  the  sexual  organs,  particular- 
ly masturbation  and  phimosis. 

A  very  interesting  example  of  acute  ataxia  due  to  mastur- 
bation is  given,  for  instance,  by  Henoch  on  page  214  of  his  text- 
book (eighth  German  edition,  1895).  This  case  refers  to  a  seven- 
year-old  boy  who  had  masturbated  since  five  years  of  age.  The 
child  was  languid,  suffered  from  sleeplessness  and  night  incontin- 
ence of  urine.  For  the  last  two  weeks  he  stopped  walking  and,  if 
not  supported,  could  not  even  stand  or  sit.  \\'hen  supported  he 
complained  of  dizziness,  moved  like  a  tabetic  patient  with  symp- 


424 


DISEASES    OF    THE    NERVOUS    SYSTEM 


toms  of  marked  ataxia ;  in  bed  all  movements  were  quite  free ;  the 
sensibility  was  preserved  ;  the  urine  and  f?eces  were  retained  with 
difficulty,  sometimes  discharged  involuntarily.  Employing  luke- 
warm baths,  of  ten  minutes'  duration,  with  cold  drenching  of  the 
head  and  the  spine,  together  with  a  careful  watching  of  the  child 
for  the  purpose  of  preventing  him  from  further  continuing  his 
habit,  there  was  noticed  after  two  weeks  a  considerable  ameliora- 
tion, and  after  one  month  complete  recovery. 

That  phimosis  may  also  be  the  cause  of  ataxia  is  shown  by 
Hunt's  case*.  A  six-year-old  boy  for  a  long  time  had  an  unsteady 
gait,  would  often  fall  and,  generally,  poorly  controlled  his  legs; 
besides  this,  twitchings  were  noticed  in  his  face ;  there  was  in- 
distinct speech,  shuddering  at  nights  and  incomplete  mobility  of 
the  tongue.  A  complete  and  rapid  recovery  took  place  upon  cor- 
recting the  phimosis  by  operation. 

In  such  cases,  as  well  as  in  cases  of  rapid  recovery  from 
paraplegia  after  the  expulsion  of  tape-worms,  it  is  well  to  bear 
in  mind  hvsteria  as  the  cause  of  ataxia,  and  that  recovery  may 
occur  through  auto-suggestion  and  in  connection  with  an  opera- 
tion. 

(4)  To  the  fourth  group  belong  cases  of  acute  ataxia  uf  cen- 
tral origin,  that  is.  cases  dependent  upon  some  affection  of  this  or 
that  portion  of  the  brain  or  spinal  cord  (see  below).  To  the  same 
class  one  should  also  refer,  with  great  probability,  the  case  of  acute 
ataxia  which  we  observed  during  the  fall  of  1895. 

B.  C,  a  seven-year-old  girl  entered  the  clinic  on  September 
6,  1895,  on  account  of  general  weakness  so  that  the  jiatient  not 
only  coiild  not  walk,  but  even  stand  or  sit. 

The  history:  The  patient  is  the  daughter  of  a  factory  work- 
man, locksmith  ;  her  father  and  mother,  as  well  as  two  brothers 
(eight  and  two  years  old)  are  well ;  no  abortions  or  still-births  in 
the  mother's  history  ;  no  signs  of  tuberculosis,  syphilis,  alcoholism 
or  nervous  disease  in  the  relatives  of  the  family.  In  the  first  year 
of  life  the  girl  was  fed  by  the  mother's  breast,  notwithstanding 
which  she  frequently  suffered  from  diarrhoea  and  therefore  began 
to  walk  late  (when  two  years  of  age).  Until  May,  1895,  did  not 
suffer  from  any  serious  diseases,  but  in  May  and  June  she  had  a 


"^Ocstcr.  Jahrb.  fi'tr  Pacd.,  1876,  s.   128. 


DISEASES    OF    THE    NEKVOUS    SYSTEM  425 

violent  cous;"h  and  fever,  ihis  disease  having-  been  determined  bv 
the  physician  as  \vhooping--cough,  complicated  with  pneimionia. 
As  soon  as  the  girl  was  through  with  this  trouble  she  again  be- 
came ill,  in  July,  with  fever  and  persistent  vomiting  which  lasted 
many  days,  and  in  the  further  course  this  was  complicated  by 
various  signs  of  acute  hydrocephalus,  as  severe  headache,  somno- 
lency, the  head  bending  backwards  and  even  general  convulsions 
came  on.  The  physician  diagnosed  titbercular  meningitis  and 
gave  an  absolutely  fatal  prognosis,  nevertheless  the  patient  began 
to  gradually  improve,  and  after  about  one  and  a-half  months  from 
the  beginning  of  the  disease,  when  the  consciousness  was  restored 
entirely  and  the  appetite  and  the  bowels  were  normal,  namely,  on 
September  6,  the  girl  was  brought  to  the  clinic,  especially  because 
she  could  neither  sit.  nor  stand,  and  had  jwor  use  of  her  arms ; 
in  general  all  movements  of  the  limbs  were  performed  w  ith  diffi- 
culty, were  languid  and  markedly  ataxic.  During  the  patient's 
three  months  sojourn  in  the  clinic  her  condition  improved  greatly. 
During^  this  time  she  was  demonstrated  to  the  students  with  the 
following  status  prcrscns: — The  patient  is  of  fair  complexion,  the 
subcutaneous  cellular  tissue  is  developed  moderately,  the  skin  and 
the  visible  mucous  membranes  are  not  very  pale ;  the  lymphatic 
glands  cannot  be  jialpated  on  the  neck,  neither  in  other  parts ; 
the  hair  and  the  nails  normal,  the  skeleton  is  formed  correctly. 
The  skull  is  symmetrical,  without  pronounced  eminences  or  de- 
pressions, painless  upon  palpation  and  percussion,  the  spinal 
colunm  entirely  movable  and  painless. 

On  the  part  of  the  digestive,  genito-urinary,  respiratory,  and 
circulatory  organs  nothing  pathological  could  be  found ;  the  ap- 
petite was  good,  the  bowels  moved  thick  freces  daily,  the  functions 
of  the  bladder  and  rectum  were  normal,  that  is, entirely  subordinate 
to  the  will ;  the  heart-sounds  were  clear,  the  pulse — about  ninety 
per  minute,  regular ;  the  dull  sound  of  the  liver  and  spleen  was 
not  increased ;  the  temperature  during  the  entire  time  of  staying 
in  the  clinic  remained  about  t,/  degrees  C.   (98.6  degrees  F.). 

On  the  part  of  the  nervous  system  the  most  striking  fact 
was  that  the  patient  entirely  lost  the  sense  of  balance.  Being  put 
on  her  feet  she  could  not  keep  her  vertical  ]x>sture  even  for  on*^ 
second,  falling  immediately  without  bending  the  logs,  the  arms 
or  the  trunk.     The  stren<^th  of  the  amis  and  le^^s  upon  coarse 


426  DISEASES    OF    THE    NERVOUS    SYSTEM 

examination  appeared  normal;  lying  in  bed  the  patient  could  bend 
and  extend  the  knees  with  such  force  that  an  adult  person  only 
with  great  strength  could  prevent  these  movements.  The  patient 
easily  performs  and  with  strength  dorsal  flexion  of  the  foot,  free- 
ly snpinates  and  extends  the  wrists.  She  could  not,  for  instance, 
touch  the  knee  with  the  heel  of  the  opposite  foot,  neither  touch 
with  the  forefinger  the  tip  of  the  nose,  etc. ;  while  it  was  not 
difficult  to  notice  that  in  the  legs  the  ataxia  was  more  expressed 

,  than  in  the  arms.  The  muscular  sense  zvas  preserved : — the 
patient  with  closed  eyes  defined  very  well  the  position  of  her 
limbs  and  recognized  passive  movements ;  muscular  iveakness 
especially  in  the  flexors  and  extensors  of  the  knee  and  foot  was  not 
noticeable,  but  the  tibio-dorsal  articulations  appeared  somewhat 
more  movable  in  normal  condition.  The  muscular  nutrition  ap- 
peared normal,  neither  atrophy,  nor  flabbiness  of  the  muscles  be- 
ing noticed  ;  on  the  contrary,  the  leg-muscles  appeared  upon  touch 
very  solid  and  elastic ;  the  same  could  be  said  concerning  the 
thigh  muscles.  The  knee-tendon  reflexes  noticeably  exaggerated, 
but  rigidity  in  the  joints  was  absent.  The  faradic  electrical  ex- 
citability of  the  muscles  of  the  leg  was  fairly  preserved,  but  some- 
what lowered  in  comparison  with  the  muscles  of  the  forearm,  as, 
for  instance,  the  contraction  of  peroneus  with  the  coil-distance 
of  65  inches  is  of  moderate  strength,  while  the  ulnaris  gives  a  vivid 
contraction  the  distance  of  the  coils  being  75  inches. 

The  tactile  and  the  pain  sensibility  were  preserved  and  ap- 
parently normal;  the  faradic  current  produced  a  painful  sensa- 
tion in  the  lower  limbs  at  the  coil  distance  of  65  to  70  inches, 

•  which  is  normal  or  almost  normal,  as  the  comparative  examina- 
tion of  a  healthy  person  showed.  The  plantar  reflexes  were 
marked,  likewise  the  abdominal  reflex  could  be  produced  easily. 
The  pupils  were  of  normal  size  and  reacted  well  to  light;  the 
pharyngeal  reflex  was  marked.  The  organs  of  vision  and  hear- 
ing were  normal.  The  speecli  was  monotonous,  interrupted, 
scanning;  the  psychical  condition  normal.  The  expression  of  the 
face  quiet,  the  facial  and  ocular  nerves  healthy,  no  headache ;  the 
sleep  was  good,  no  complaint  of  any  pain ;  pressure  over  the  tract 
of  the  sciatic  nerve  and  the  muscles  of  the  thigh  and  legs  pain- 
less. 

The  diagnosis  is  quite  difficult  in  the  given  case.     The  fact 


DISEASES    OF    TJ11-:    XEKVOUS    SVSTICM  42/ 

that  in  a  j^rcat  majority  of  cases  acute  ataxia  depends  upon  affec- 
tion of  peripheral  nerves  leads  to  the  belief  that  this  is  one  of 
the  cases  of  multiple  neuritis,  the  so-called  tabes  peripherica.  But 
such  a  diagnosis  is  improbable,  because  there  are  no  symptoms  of 
neuritis  (neither  pains  along  the  course  of  the  nerves,  changes 
-of  sensibility,  nor  pareses,  even  in  the  area  of  the  peroneal  nerve, 
as  the  dorsal  flexion  of  the  foot  was  performed  with  force ;  nor 
lowering  of  the  reflexes).  And  there  are  facts  which  are  against 
such  a  diagnosis,  namely,  the  onset  of  the  disease  with  meningitis, 
a  noticeable  increase  of  the  reflexes  and  normal  condition  of  nutri- 
tion of  the  muscles  of  the  legs. 

Hysterical  astasia-abasia  was  also  absent  (the  patient's  age, 
-the  onset  of  the  disease,  scanning  speech,  ataxia  upon  moving  the 
limbs  in  the  lying  posture). 

It  is  most  probable  to  suppose  here  some  Ventral  lesi(ni  of 
-the  brain  and  spinal  cord,  as,  for  instance,  of  the  cerebral  cortex 
(cortical  ataxia),  of  the  cerebellum  (cerebellar  ataxia),  of  the 
pons  Varolii  and  medulla  oblongata  (bulbar  ataxia),  and  it  is  no 
■doubt  true  that  in  the  brain  and  the  spinal  cord  there  are  some 
-other  portions  a  lesion  of  which  leads  to  ataxia. 

In  order  to  determine  the  location  of  the  morbid  process 
producing  ataxia  in  each  separate  case  one  must  give  heed  to 
the  character  of  the  ataxia,  to  the  concomitant  symptoms  and  to 
.the  aetiological  factors  as  well. 

As  to  the  character  of  the  ataxia  and  concomitant  symptoms, 
it  is  necessary  to  point  out  regarding  cortical  aia.via,  that  the 
Jatter  is  often  unilateral  (bilateral  ataxia  without  idiocy,  although 
-theoretically  possible,  occurs  very  rarely),  quickly  develops  to  a 
-considerable  extent,  gradually  extends  according  to  the  distribu- 
tion of  separate  centers,  at  first  the  legs  becoming  paralyzed, 
then  the  arms  and  finally  over  the  course  of  the  facial  and  hypo- 
:glossal  nerves. 

Besides  ataxia  still  other  symptoms  of  cortical  lesion  may  ap- 
pear, as  cortical  epilepsy,  paralyses  and  aphasia. 

In  cerebellar  ataxia  the  patient  complains  of  headache ;  in 
•walking  he  swings  from  one  side  to  the  other,  as  if  drunk,  be- 
cause of  loss  of  the  sense  of  balance,  but  when  lying  in  bed  he 
moves  his  limbs  correctly,  without  manifesting  any  ataxia:  the 
.arms  do  not  1)ecomc  involved.     In  our  case  altb.oiiuli  the  loss  ot  the 


428  DISEASES    OF    THE    NERVOUS    SYSTEM 

sense  of  co-ordination  was  very  prominent,  yet  ataxia  was  noticed 
in  the  movements  when  the  patient  was  lying  down,  not  only  in 
the  lower,  but  also  in  the  upper  limbs. 

In  bulbar  ataxia  all  four  extremities  become  involved  simul- 
taneouslv  with  the  appearance  of  bulbar  symptoms,  which  was  ab- 
sent in  our  case. 

It  is  most  probable  that  in  our  case  we  had  to  do  with  ataxia 
of  spinal  ori(^iii,  with  that  form  which  is  the  manifestation  of 
disseminated  inflaniniation  of  the  spinal  cord — myelitis  dissemi- 
nata. As  this  morbid  form  is  not  described  in  the  majority  of 
text-books  it  is  very  little  known  to  physicians.  For  this  reason 
we  deem  it  best  to  describe  the  disease  more  at  lens^th,  being 
guided  by  Leyden  and  Goldscheider's  monograph  in  Nothnagel's 
Encyclopaedia*. 

Leyden  and  Goldscheider  say  that  the  picture  of  acute  ataxia 
may  be  produced  by  two  separate  processes ;  first,  by  polyneuritis^ 
and,  secondly,  by  disseminated,  insular  affection  of  the  central 
nervous  system,  particularly  in  the  region  of  the  spinal  cord  and 
medulla  oblongata,  pons  X'arolii  and  cerebral  peduncles.  This 
latter  form  is  described  b\-  Leyden  and  (ioldscheider  under  the 
name  of  acute  (bulbar)  ataxia. 

According  to  Westphal,  who  described  the  greatest  number  of 
cases  of  acute  ataxia,  the  most  characteristic  symptoms  of  the 
disease  in  question  ars  the  following : — 

{i)A  peculiar  disorder  of  speech:  the  patient's  speech  is 
slow,  drawling,  scanning. 

(2)  Ataxia  of  the  limbs,  the  muscular  force  being  preserved 
or  at  any  event  only  inconsiderably  decreased. 

(3)  Unimpaired  sensibility. 

(4)  Disorders  of  psychical  condition  in  the  form  of  excita- 
tion or  weakening  of  the  memory  and  even  dementia. 

According  to  Leyden,  myelitis  disseminata  (encephalomyeli- 
tis) presents  two  entirely  different  forms  of  disease — acute  ataxia 
and  paraplegia. 

The  most  noticeable  symptom  of  the  first  form  is  acute  ataxia 
spreading  all  over  the  four  extremities,  although  not  equally ;  the 
voluntary  movements  are  often  not  only  ataxic,  but  also  retarded^ 


''Vol.  X.,   Part  II.,  page  404. 


DISEASES    OF    THE    NERVOUS    SYSTEM  429 

languid  ;  the  coarse  strength  of  the  muscles,  if  decreased,  then 
only  to  a  very  inconsiderable  degree ;  actual  paralyses  occurring 
very  seldom ;  the  muscles  are  generally  relaxed.  Sometimes  to- 
gether with  ataxia  tremor  is  also  noticed,  especially  upon  active 
movements.  (  )n  ilie  part  of  the  eyes  there  is  often  nystagmus. 
Disorder  of  speech  is  noticed  almost  always ;  it  is  scanning,  drawl- 
ing, retarded,  monotonous.  The  functions  of  the  rectum  and 
bladder  are  normal.  Subjective  disorders  of  sensibility  and  pains 
are  absent,  the  objective  examination  detecting  only  inconsiilerable 
deviations  from  the  normal  standard.  The  muscular  sense  is  in 
the  majority  of  cases  normal.  Cutaneous  reflexes  are  normal,  the 
tendon  reflexes  may  be  exaggerated.  The  pupil-reflexes  are  not 
changed.  The  mental  abilities  are  often  weakened,  as  illustrated 
in  the  power  of  the  memory,  which  sometimes  limits  the  mental 
impairment. 

The  course.  The  disease  begins  acutely  or  subacutely.  In 
some  cases  after  a  foudroyant  onset  all  symptoms  quickly  decrease, 
and  after  a  few  weeks  complete  recovery  follows;  in  other  cases 
after  a  seeming  recovery  relapses  come  on,  and  the  process  may 
end  with  the  development  of  multiple  sclerosis.  Some  cases  as- 
sume a  chronic  course  at  once  being  transformed  into  a  type  of 
multiple  sclerosis  of  uncertain  duration. 

The  pathological  anatomy.  Inflammatory  foci  of  various, 
usually  of  inconsiderable,  size  are  in  some  cases  limited  to  the 
spinal  cord,  in  others  they  also  mvolve  the  bulb,  pons  V^arolii, 
cerebral  peduncles  and  even  sometimes  the  hemispheres.  They  are 
located  in  the  gray,  as  well  as  in  the  white,  matter.  In  general, 
the  pathological  process  bears  the  character  of  perivascular  inflam- 
mation. In  the  further  course  the  inflammatory  feci  probably  be- 
come transformed  into  the  condition  of  sclerosis,  that  is,  trans- 
formed into  multiple  sclerosis. 

Mtiology : — 

(i)   Heredity  is  of  no  particular  importance. 

(2)  Trauma  may  be  the  accidental  cause. 

(3)  The  chief  setiological  influences  belong  to  the  acute  in- 
fectious diseases ;  small-pox,  typhoid  fever,  whooping-cough, 
erysipelas,  measles,  dysentery,  influenza,  malaria,  rabies,  tubercu- 
losis and  probably  also  parotitis  epidemica  (mumps). 

The  first   symptoms  of  myelitis  set    in    either    during    the 


430  DISEASES    OF    THE    XERVOUS    SYSTEM 

highest  development  of  the  disease,  or  oftener  in  the  period  of 
recovery. 

(4)  Of  some  importance  are  the  intoxications,  for  instance, 
by  CO  and  metals. 

(5)  Sometimes  no  etiological  relationship  can  be  detected, 
such  cases  being  described  as  "spontaneous  myelitis." 

Returning  to  our  case  then,  we  will  see  that  in  its  rapid 
onset,  which  simulated  inflammation  of  the  cerebral  membranes ; 
in  the  pronounced  ataxia  of  all  four  extremities  while  paralyses 
and  disorders  of  sensibility  were  absent ;  in  the  scanning,  monot- 
onous speech,  in  the  absence  of  muscular  atrophies  and  increase 
of  the  tendon  reflexes  it  entirely  agrees  with  the  description  of 
Leyden  and  Goldscheider  under  the  name  of  myelitis  disseminata 
s.  ataxia  acuta  (bulbaris).  The  termination  of  the  disease  in 
our  case  does  not  contradict  this  diagnosis ;  the  patient  was  dis- 
charged from  the  clinic,  with  considerable  improvement,  in  Janu- 
ary. She  could  stand  for  a  short  time  without  being  supported,, 
could  walk  around  the  bed,  holding  by  its  edge;  could  creep  in 
the  bed,  without  aid.  In  the  spring  she  could  walk  without  any 
support. 

As  to  the  diagnosis  of  the  causes  of  acute  ataxise  in  general 
the  same  may  be  readily  determined  by  the  history.  Diphtheri- 
tic ataxia  may  be  diagnosticated  with  comparatively  little  diffi- 
culty inasmuch  as  it  is  preceded,  and  not  rarely  followed,  by 
characteristic  symptoms  of  paralysis  of  the  soft  palate  and  the 
pharynx. 

From  chronic  ataxia  the  acute  forms  differ  mostly  by  the 
rapidity  of  development  of  the  symptoms. 

The  prognosis  in  acute  ataxia  is  generally  favorable  as  in 
the  majority  of  cases  complete  recovery  sets  in  in  a  few  weeks 
or  months ;  in  severe  cases  even  a  fatal  termination  may  occur, 
for  instance  in  diphtheritic  ataxia  due  to  paralysis  of  the  heart. 
In  myelitis  disseminata  the  issue  may  be  in  chronic  multiple 
sclerosis. 

Chronic  ataxia  in  childhood  is  a  symptom  either  of  disease 
of  the  brain  or  spinal  cord.  In  the  former  case  the  diagnosis  is 
based  upon  the  associated  symptoms  which  usually  show  the  pres- 
ence of  a  tumor  in  the  cranial  cavity  or  hydrocephalus.  In  such, 
cases  ataxia  is  only  of  secondary  importance.     On  the  contrary. 


disi-:asf:s  ftp  the  xervocs  system  4^ 

it  is  the  chief  symptom  in  so-called  Friedreich's  disease,  or  hcrcch- 
tary  ataxia,  which  in  its  anatomical  features  must  be  held  as  a 
combined  systemic  disease,  because  the  autopsy  always  shows  de- 
generation of  the  posterior  and  pyramidal  columns  simultaneously, 
and  sometimes  also  of  Clarke's  columns  and  the  cerebellar  tracts. 

The  leading;  symptoms  of  this  disease  are : — ataxia,  loss  of 
tendon  reflexes,  nystaguius  and  tremor  of  the  limbs  during  inten- 
tional movements.  Ataxia  in  its  character  is  somewhat  like  the 
cerebellar  form,  because  in  walking  the  patient  sways  from  one 
side  to  another ;  nystagmus  is  almost  always  present,  but  in  some 
patients  it  is  not  noticeable  during-  the  quiet  condition  of  the  eyes, 
but  makes  itself  evident  only  upon  movements  of  the  eye-ball,  for 
instance,  when  the  patient  is  directed  to  follow  an  object  moving 
before  the  eyes  to  the  right  or  to  the  left  side.  A  very  important 
symptom  of  Friedreich's  disease  is  also  impairment  of  speech, 
which  is  monotonous  and  indistinct ;  the  tongue  when  extended 
manifests  oscillating  movements  or  twitchings. 

As  to  the  distinction  of  this  disease  from  a  common  tabes 
dorsalis  which,  however,  hardly  ever  occurs  in  childhood,  it  is 
based  upon  the  absence  of  some  symptoms  ver}^  characteristic  of 
the  latter.  For  instance,  m  Friedreich's  ataxia  disorders  of 
cutaneous  sensibility  and  of  the  muscular  sense,  optic  atrophy, 
changes  in  the  pupillary  reaction  and  impairment  of  the  functions 
of  the  bladder  and  rectum  are  absent,  while  there  is  present 
nystagmus  which  is  not  peculiar  of  tabes,  and  impairment  of  speech. 
As  common  symptoms  for  both  these  diseases  there  remain  ataxia 
and  absence  of  tendon  reflexes. 

[O.  Marburg,  of  Vienna,  collected  34  cases  of  infantile  and 
juvenile  tabes.  We  speak  of  infantile  tabes,  if  the  disease  mani- 
fests itself  before  fifteen  years  of  age ;  if  it  arises  after  this  date, 
then  it  is  denominated  juvenile  tabes.  Of  the  34  cases  Marburg 
collected  from  literature  19  were  females  and  15  males,  the  ratio 
thus  being  4:3,  while  in  adults  this  ratio  is  reversed  decidedly, 
i.  e.,  the  disease  occurring  oftener  in  males  than  in  females  as 
10:1. 

The  cause  of  infantile  or  juvenile  tabes  is  syphilis  (in  the 
majority  of  cases).  From  the  time  of  specific  infection  up  to 
the  appearance  of  the  tabetic  symptoms  there  is  a  period  of  from 
five  to  nineteen  years  (the  same  as  in  adults). 


432  DISEASES    OF    THE    NERVOUS    SYSTEM 

All  symptoms  usually  observed  in  adults  are  also  characteris- 
tic of  the  juvenile  form ;  but  the  most  important  and  the  earliest 
symptoms  of  tabes  in  children  are  optic  atrophy  and  vesical  dis- 
orders. (3f  the  latter  incontinence  of  urine  occurs  much  oftener 
than  retention.  It  may  be  dififerentiated  from  a  vesical  neurosis 
— nocturnal  enuresis — by  occurring  also  in  the  day  time  and  by 
being  accompanied  by  visual  disorders.  Crises  and  trophic  dis- 
turbances are  also  frequent  in  children,  but  much  less  so  than  in 
adults. 

In  addition  to  the  34  cases  taken  from  literature  Marburg 
adds  one  of  his  own :  A  ten-year-old  boy  contracted  syphilis 
from  the  wet-nurse  when  one  and  a-half  years  of  age.  He  was 
cured  bv  mercurial  frictions  (half  a  dram  of  blue  ointment — 30 
frictions)  and  was  free  from  any  disorders  up  to  the  eighth  year 
of  age,  when  his  vision  began  to  suffer ;  and  could  not  be  relieved 
by  glasses.  Upon  examination  there  were  found :  unequal  pupils, 
with  slui^^^ish  reaction  to  light  (on  the  left  side)  and  complete 
absence  of  the  reaction  on  the  right  side,  the  right  papilla  was 
pale  (optic  atrophy),  accommodative  reaction  of  the  pupils — nor- 
mal. There  was  absence  of  the  patellar  reflex;  slight  tottering 
with  closed  eyes  (Romberg's  phenomenon)  ;  the  mental  condi- 
tion was  entirely  normal.  The  beginning  of  the  disease  thus  oc- 
curred with  the  optic  atrophy*. — Earle.] 

Intentional  tremor,  nystagmus,  impairment  of  speech  and 
ataxia  occur  also  in  sclerosis  disseminata,  which  disease  is  very 
rarely  met  with  in  children.  The  substantial  differences  consist 
in  the  tendon  reflexes  being  increased  in  sclerosis,  the  course  of 
the  disease  being  interrupted  by  apoplectiform  attacks  and  consid- 
erable temporary  aggravations. 

The  diagnosis  of  Friedreich's  disease  may  be  assisted  in  many 
cases  by  the  hereditary  character  of  the  disease,  that  is,  by  its 
occurring  either  in  all,  or  at  least  in  some,  members  of  the  same 
family. 

This  sign  is  also  peculiar  of  that  form  of  ataxia  which  was 
described  by  Marie  as  Heredoataxie  cerebelleuse  (Hereditary 
cerebellar  ataxia) ,  but  in  this  form  the  tendon  reflexes  are  retained 
or  even  exaggerated,  the  arms  either  do  not  become  involved. 


*Otto  Marburg:  Infantile  und  Juvenile  Tales  {Wiener  Klin.  Wochen- 
schr.,  1903,  No.  47). 


nisiiASEs  OF  Tin-:  nervous  svsTK.\r  433 

or  very  late,  the  muscles  of  the  lower  limbs  are  in  the  condition 
of  spasm,  there  often  develops  optic  atrophy,  while  aetiologicallv 
there  is  a  substantial  difference  in  the  age  in  which  the  disease 
begins.  Friedreich's  disease  begins  in  the  age  of  from  seven  up 
to  fifteen  years,  while  cerebellar  ataxia  from  twenty  up  to  forty 
years. 

INFLAMMATION  OF  THE  CEREBRAL   MENINGES, 

In  accordance  with  the  aetiology,  pathogenesis  and  clinical 
course  four  forms  of  acute  inflammation  of  the  cerebral  meninges 
in  children  may  be  described : — 

( 1 )  Purulent   meningitis. 

(2)  Tubercular  meningitis,  or  acute  tubercular  hxdro- 
cephalus. 

(3)  Serous  meningitis,  or  simple  acute  hydrocephalus. 

(4)  Epidemic  cerebro-spinal  meningitis. 

In  the  simple  (non-tubercular)  acute  purulent  inflanimatiou 
■ — men'moitis  acuta  simplex — the  pia  mater  over  the  convexity  of 
the  hemispheres  becomes  especially  affected  (hence  the  name 
lepto-meningitis  convexa)  ;  pathologico-anatomically  it  is  char- 
acterized by  the  formation  of  a  purulent  exudation,  hence  also 
called  meningitis  purulenta. 

The  tubercular  form  of  inflammation  of  the  cerebral  meninges 
dift'ers  from  the  preceding,  among  other  features,  by  the  leading 
alterations  being  located  in  the  membranes  of  the  base  of  the 
brain,  therefore  the  name  meningitis  basilaris.  The  presence  of 
pus  is  in  this  case  unnecessary,  being  frequently  absent  altogether 
and  the  inflammation  manifested  by  the  formation  of  a  serous 
exudate,  which  principally  accumulates  in  the  subachnoidean 
spaces,  between  the  optic  chiasma  and  the  bulb,  as  well  as  in  the 
lateral  ventricles  which  therefore  become  considerably  distended 
in  all  cases.  This  form  is  also  called  acute  hydrocephalus — hydro- 
cephalus acutus,  and  is  especially  notable  because  of  the  presence 
of  extensive  deposits  of  miliary  tubercles  at  the  base  of  the  brain, 
accumulated  mostly  in  the  sylvian  grooves — meningitis  tuber- 
culosa. As  tuberculosis  is  almost  never  localized  solely  in  the 
cerebral  membranes,  deposits  are  therefore  found  post  mortem  in 
other  organs,  especially  in  the  bronchial  glands. 

It  is,  however,  undoubted  that  acute  hydrocephalus  of  in- 
flammatory origin  (meningitis  serosa)  sometimes  occurs  in  chil- 


434  DISEASES    OF    THE    NERVOUS    SYSTEM 

dren  (especially  under  two  years  of  age)  even  without  tuber- 
culosis, that  is,  in  the  complete  absence  of  tubercles  not  only  in 
the  cerebral  meninges,  but  elsewhere  in  the  organism.  In  tuber- 
cular meningitis,  as  well  as  in  this  form,  there  may  be  pus  to- 
gether with  the  serous  exudation. 

This  form  is  described  in  some  text-books  in  a  separate 
chapter  under  the  name  of  simple  (non-tubercular)  acute  hydro- 
cephalus— hydrocephalus  acutus  simplex  s.  non-tuberculous  or  in- 
fantile meningitis — leptomeningitis  infantum  (Huguenin),  be- 
cause it  is  peculiar  to  childlKX>d.  But  as  in  the  symptoms  and 
the  course  a  simple  hydrocephalus  differs  in  no  way  peculiar 
from  the  tubercular  form,  therefore  it  is  not  necessary  to  describe 
it  separately ;  it  suffices  to  know  that  such  a  form  does  exist  and 
that  this  may,  contrar}'  to  tubercular  meningitis,  end  with  re- 
covery, so  that  one  can  by  no  means  hold  to  a  hopeless  prognosis^ 
that  is,  to  an  absolutely  fatal  lesion,  because  the  patient  exhibifs 
symptoms  of  tubercular  meningitis. 

Epidemic  cerebrospinal  meningitis — meningitis  cerehro- 
spinalis  epidcviica — is  characterized  by  the  formation  of  a  puru- 
lent exudation  on  both  the  convexity  and  the  base  of  the  brain 
and,  besides  this,  by  affection  also  of  the  spinal  membranes. 

Pathologico-anatomically  these  four  forms  strikingly  differ 
from  each  other  only  in  their  typical  manifestations,  simultaneous- 
ly with  which  still  different  transitory  forms  are  met  with,  as,  for 
instance,  in  meningitis  purulenta  the  purulent  exudation  may 
spread  to  the  base  of  the  brain  and  the  choroid  plexuses  of  the 
ventricles.  Acute  tubercular  hydrocephalus  (tubercular  or 
simple)  is  sometimes  accompanied  by  the  formation  of  pus  not 
only  at  the  base  of  the  brain,  but  also  on  the  convexity  of  the 
hemispheres.  In  the  simple  purulent  as  well  as  in  tubercular 
meningitis  the  inflammation  may  also  involve  the  spinal  mem- 
branes, as  in  epidemic  meningitis.  It  is  self-evident  that  the 
similarity  may  clinically  be  still  greater  and  therefore  it  is  no- 
wonder  that  in  some  cases  it  is  very  difficult  to  say  with  which 
particular  form  we  have  to  deal.  An  important  aid  to  diagnosis 
in  such  cases  is : — 

/Etiology : — In  distinction  from  .all  other  forms  of  inflamma- 
tion of  the  meninges  tubercular  meningitis  never  affects  entirely 
healthy  children  inasmuch  as  its  chief  setiological  factor  is  general 


DISEASES    OF    THE    Nl-.K\()rS    SVSTK^[  435 

or  local  tuberculosis.  Therefore  it  is  important  for  its  (lia.i,Mi()sis 
to  note  the  predisposition  of  a  given  child  to  tuberculosis.  This 
disposition  may  be  hereditary  or  acquired.  To  ascertain  the 
former  the  physician  inquires  if  there  was  not  tuberculosis  in 
the  parents  or  the  nearest  relatives,  and  if  some  of  the  sisters  or 
brothers  did  not  die  from  a  disease  bearing  some  relation  to  tuber- 
culosis. In  this  regard  it  is  most  important  to  know  if  there  were 
not  cases  of  death  due  to  meningitis.  There  are  unfortunate 
families  in  which  several  children  in  succession,  and  at  approxi- 
mately the  same  age.  die  from  meningitis,  although  neither  the 
father,  nor  the  mother,  suffer  from  tuberculosis. 

Hereditary  disposition  to  tuberculosis  in  children  may  be  the 
consequence  of  other  diseases  in  parents,  for  instance,  of  an  old 
syphilis.  I  know  a  family  in  which  four  children  died  from  tul>er- 
cular  meningitis,  notwithstanding  that  the  father  and  the  mother 
seemed  to  be  entirely  well.  The  father  had  a  scar  upon  the 
shoulder  caused  by  an  old  caries  apparently  of  scrofulous  origin. 
Syphilis,  many  years  before,  was  brought  out  in  his  history,  but 
his  then  present  condition  was  one  of  good  health.  After  the 
death  of  the  fourth  child  he,  according  to  his  physician's  advice, 
underwent  anti-syphilitic  treatment  by  mercurial  inunctions  (blue 
ointment)  and  after  one-and-a-half  years  two  children  were  born 
who  have  survived  the  dangerous  age  and  are  at  present  entirely 
healthy. 

The  family  predisposition  to  tuberculosis  may,  in  a  given 
case,  also  be  denoted  by  the  death  of  brothers  or  sisters  from 
measles  and  whooping-cough.  In  entirely  healthy  children  these 
diseases  usually  have  a  favorable  course,  but  they  are  dangerous 
in  the  presence  of  some  predisposition  to  tubercidosis. 

The  acquired  disposition  develops  under  the  influence  of  all 
unfavorable  conditions  which  are  of  importance  as  astiological 
factors  of  rachitis  and  scrofulosis,  therefore,  if  the  child  shows- 
symptoms  of  this  or  that  disease,  then  one  may  think  that  he- 
has  some  disposition  to  tuberculosis.  The  generally  healthy  aspect, 
in  such  instances  does  not  prove  the  contrary,  as  under  the  in- 
fluence of  rachitis  there  may  develop  in  some  parts  of  the  body 
(bronchial  glands)  caseous  (tubercular)  foci  which  do  not  in 
any  way  manifest  their  presence  for  some  time,  but  finally  give.- 
rise  to  the  auto-infection  of  the  orqanism  hv  lubercio  baciili. 


436  DISEASES    OF    THE    NERVOUS    SYSTEM 

Such  latent  nests  most  often  remain  in  the  hronchial  or 
mesenteric  glands  after  old  catarrhs  to  which  rachitic  and  scrof- 
ulous children  are  so  prone,  therefore  one  must  inquire  if  the 
child  did  not  sufifer  with  repeated  or  chronic  bronchites  and 
diarrhaae. 

There  are  diseases  after  which  the  latent  disposition  to  tuber- 
culosis suddenly  appears  as  nienmgitis  or  acute  miliary  tuber- 
culosis, etc.,  and  this  fact  (that  is,  that  the  attacks  began  to 
manifest  themselves  after  such  and  such  disease)  may  occasion- 
allv  be  of  great  value  in  the  diagnosis,  for  instance,  of  typhoid 
from  tuberculosis.  Of  prime  importance  among  such  diseases 
are  measles,  la  grippe  and  whooping-cough,  secondarily,  different 
wasting  diseases. 

Accidental  causes  are  unnecessary  in  the  incidence  of  tuber- 
cular meningitis,  as  the  disease  usually  develops  without  any 
certain  cause ;  in  other  cases  there  are  indications  of  exposure  to 
cold  or  contusion  of  the  head  ( usually  a  very  slight  one  which  is 
hardly  of  any  value). 

The  age  mostly  favoring  the  development  of  tubercular  men- 
ingitis is  that  from  two  to  seven  years,  but  nurslings  and  adults 
sometimes  become  affected. 

Contrary  to  this  a  simple  serous  meningitis  ( simple  acute 
hydrocephalus)  most  frequently  (almost  exclusively)  occurs  in 
small  children  during  the  first  or  second  year  of  life. 

Another  ^etiological  ditTerence  from  the  tubercular  form 
consists  in  the  simple  variety  affecting  not  only  rachitic,  but  also 
entirely  healthy  children  having  neither  an  hereditary  or  acquired 
disposition  to  tuberculosis ;  and  it  usually  develops  without  any 
determinable  cause.  Oftener,  however,  1  have  met  the  condition 
in  weak  children  presenting  rachitic  changes  in  the  bones  of  the 
skull  and  chest  wall,  or  in  children  who  have  repeatedly  had 
eclamptic  convulsions.  Some  authors  ascribe  the  iniiuence  of 
dentition  as  a  factor  disposing  children  to  cerebral  congestions  and 
acute  hydrocephalus. 

A  simple  acute  purulent  meningitis  never  develops  in  healthy 
children  without  evident  cause,  therefore  if  no  suitable  data  can 
be  found  in  the  history,  then  this  circumstance  alone  makes  the 
diagnosis   of   simple   purulent   meningitis    little   probable,      even 


nisF,.\SEs  OF  Till';  .\i:k\()Us  system  ^ly 

thougli  symptoms  so  indicate.  We  usually  have  to  do  in  sucii 
cases  with  cerebro-spinal  meningitis  of  infectious  origin.  A 
healtln  and  strong  child  may  come  down  with  meningitis  because 
of  a  contusion  or  severe  cold  of  the  head,  or  because  of  insola- 
tion. In  other  cases  again  meningitis  develops  because  of  ex- 
tension of  an  inflammation  from  neighboring  parts  or  as  a  com- 
plication of  different  acute,  infectious  diseases.  In  the  former 
case  the  most  fre(|uent  cause  is  acute  or  chronic  otitis  media,  or 
again  caries  of  tlie  skull  bones  associated  with  other  causes 
(periositis,  gummata),  erysipelas  of  the  head,  furunculosis.  etc. 
As  a  complication  of  acute  diseases  meningitis  most  often  occurs 
in  croupous  pneumonia,  somewhat  less  frequently  in  scarlet  fever, 
acute  rheumatism,  small-pox  and  pyaemia. 

Epidemic  cerebro-spinal  meningitis,  as  the  name  indicates, 
develops  under  the  influence  of  epidemic,  as  yet  unknown,  con- 
ditions. The  post  mortem  most  often  shows  the  intracellular 
diplococcus.  The  same  microbe  commonly  occurs  also  in  siwradic 
cases  of  cerebro-spinal  meningitis :  some  authors  refer  the  same 
to  contagious  diseases,  but  its  contagiousness  is  at  most  not 
great. 

Let  us  ])rocee<l  now  to  the  symptoms.  (_)f  all  severe  cerebral 
diseases  in  children   tubercular  meningitis  is  the  most  comm<in. 

Notwithstanding  the  fact  that  there  is  no  symptom  whicii 
can  be  held  as  pathognomonic  of  tubercular  meningitis  the  diag- 
nosis of  this  disease,  in  the  overwhelming  majority  of  cases,  does 
not  exhibit  any  difficulties,  because  of  the  combination  of  all 
symptoms  as  well  as  of  the  course. 

In  distinction  from  all  other  forms  of  meningitis  i  ii'.i'.rcl'Lar 
MEXixGiTis  almost  never  begins  suddenly  amid  eomplete  health, 
on  the  contrary,  several  weeks  previous  to  the  ap])earance  of 
headache  and  vomiting  the  patient  manifests  uncertain  symptoms 
of  general  malaise  wdiich  constitutes  the  scvcalled  period  of  [pre- 
cursors of  tubercular  meningitis.  This  period,  according  to  Ril- 
liet  and  Barthez,  may  even  be  absent  sometimes,  but  only  perhaps 
in  hospital  patients,  to  whom  the  associates  i)ay  little  attention, 
and  do  not  thus  notice  trilics ;  but  in  private  practice  one  always 
succeeds  in  obtaining  the  history  of  the  precursory  symptoms. 
However,  this  is  not  always  correct.  The  symptoms  of  this  period 
are  explained  by  the  tuberculosis  developing  in  general  in   the 


438  DISEASES    OF    THE    NERVOUS    SYSTEM 

organism,  and  it  is  not  a  necessary  consequence  that,  after  such 
symptoms,  the  tuberculosis  should  be  localized  in  the  meninges ; 
it  may  be  limited  to  the  lungs  or  peritoneum,  etc.  The  sooner  the 
cerebral  membranes  take  part  in  the  affection,  the  shorter  the 
precursory  period  will  be,  and  as  in  childhood  the  pia  mater 
sometimes  becomes  involved  primarily  and  alone,  then  the  period 
of  incipiency  may  be  absent.  It  is  true  that  such  cases  are  rare, 
but  they  nevertheless  must  be  borne  in  mind  in  order  not  to 
regard  the  absence  of  the  period  in  question  as  being  of  prime 
importance. 

Thus,  the  period  of  precursors  denotes  a  beginning  tuber- 
culosis, being  most  often  manifested  by  symptoms  of  general 
malnutrition  in  the  form  of  wasting  (especially  is  this  noticeable 
on  the  chest  wall  and  neck,  but  not  on  the  face),  pallor  of  the 
integument  and  loss  of  appetite ;  headache,  fever  and  diarrhoea 
being  absent.  The  parents  also  complain  that  the  child  is 
languid,  lazy  and  irritable,  whining,  and  all  this  "without  any 
cause." 

In  other  cases  this  pericxl  manifests  itself  in  the  form  of 
more  or  less  continued  fever  without  any  local  symptoms  and  is 
therefore  often  mistaken  for  typhoid,  although  spleen  tumor  is 
often  absent.  If  such  a  fever  (that  is,  without  local  symptoms) 
appear  in  a  child  who  shortly  l>efore  had  measles  or  la  grippe,  or 
is  suffering  from  whooping-cough,  then  this  fact  alone  is  in  favor 
of  a  developing  tuberculosis,  making  improbable  the  supposition 
of  typhoid  fever  in  the  patient.  Such  a  fever  may  last  two  or 
three  weeks  before  the  cerebral  symptoms  make  themselves  evi- 
dent, as,  for  instance,  in  one  of  my  cases,  a  five-year-old  boy, 
tuberculous  fever  with  the  symptoms  of  an  insignificant  bronchi- 
tis, which  would  disappear,  and  then  reappear,  started  during 
whooping-cough  and  lasted  one  hundred  and  nine  days,  until 
vomiting  and  headache  finally  appeared.  (About  the  peculiarities 
of  tuberculous  fever,  as  well  as  of  its  differences  from  typhoid, 
see  the  section  on  typhoid).  An  afebrile  precursory  period  may 
also  last  from  two  up  to  twelve  weeks. 

The  onset  of  meningitis  proper  occurs  with  vomiting  and 
headache.  (The  dift'erentiation  of  meningeal  vomiting  from  gas- 
tric was  mentioned  in  the  section  on  vomiting,  page  155).  Vomit- 


DISEASES    OF    THE    NERVOUS    SYSTEM  439 

ing  rarely  lasts  more  than  five  days  and  if  an  entire  twenty-four 
hour  period  has  passed  without  vomiting,  then  one  may  infer 
the  same  will  not  return.  Vomiting  is  one  of  the  most  important 
symptoms  of  meningitis,  especially  because  of  its  constancy  as 
such.  It  almost  never  is  absent ;  so  that  in  doubtful  cases  the 
absence  of  vomiting  in  the  commencement  of  the  disease  almost 
excludes  meningitis.  Often  there  occur  cases  of  meningitis  in 
which  the  vomiting  is  not  obstinate,  for  instance,  a  single  attack. 
As  to  headache,  this  is  not  so  severe  in  tubercular  meningitis, 
as  in  purulent  or  cerebro-spinal ;  it  does  not  make  an  older  child 
throw  himself  about  in  the  bed,  or  cause  him  to  groan  and  grasp 
his  head,  l)ut  he  usually  complains  of  the  same  when  asked  what 
hurts  him.  This  fact  must  be  borne  in  mind  in  order  not  to 
exclude,  in  the  differential  diagnosis,  a  cerebral  lesion  only  be- 
cause the  headache  is  insignificant. 

In  the  onset  of  tubercular  meningitis  restlessness  is  not 
peculiar,  on  the  contrary  there  is  a  slight  apathy ;  the  child  keeps 
quiet  in  bed,  does  not  complain  or  ask  for  anything;  he  does  not 
create  the  impression  of  being  severely  ill  altogether,  being  only 
weak  and  unable  to  walk,  mostly  because  of  di::cincss. 

In  young  children  acute  hydrocephalus  is  seemingly  accom- 
panied by  more  considerable  headache,  because  during  the  first 
days  of  the  disease  there  appears  together  with  vomiting  con- 
siderable restlessness,  so  that  the  child  cries  very  much  during 
the  day  time  as  well  as  at  night.  Such  a  restlessness  is  undoubt- 
edly of  diagnostic  value  in  the  differentiation  between  meningeal 
vomiting  and  the  gastric  variety,  in  which  the  child  remains  com- 
paratively quiet. 

During  the  following  days  the  most  characteristic  sign  is  the 
gradual  and  progressive  increase  of  apathy  to  the  point  of  somno- 
lency, which  is  transformed  toward  the  end  of  the  disease  into 
complete  coma.  The  increase  of  apathy  is  manifested  by  the 
child  often  falling  into  an  apparently  normal,  quiet  sleep.  At 
first  the  usual  call  is  sufificient  to  awaken  the  child,  his  conscious- 
ness being  still  well  preserved ;  he  correctly  answers  questions 
and  fulfills  what  he  is  ordered,  but,  being  left  alone,  he  very 
soon  closes  his  eyes  and  sleeps  again.  It  seldom  happens  that  the 
child  is  very  delirious  in  the  first  period  of  tubercular  meningitis, 
or  that  he  jumps  from  the  bed,  constantly  talking,  etc.      (These 


440  DISEASES    OF    THE    NERVOUS    SYSTEM 

symptoms,  dependent  upon  involvement  of  the  cerebral  cortex, 
are  more  peculiar  of  purulent  mening:itis  of  the  convexity  of  the 
hemispheres).  Later  on  the  somnolency  is  deeper,  the  child 
awakes  only  upon  painful  irritations,  still  later  he  reacts  to 
them  only  reflexly,  and  shortly  before  death  the  reflexes  also 
disappear. 

The  apathetic  condition  in  nurslings  is  shown  b}'  the  tendency 
to  sleep,  and  therefore  it  is  very  characteristic  of  a  beginning 
meningitis  that  the  child,  after  having  suffered  several  days  (three 
to  six)  with  vomiting,  restlessness  and  poor  sleep,  begins  to  fall 
asleep  even  during  the  day,  while  vomiting  either  stops  entirely, 
or  becomes  lessened. 

Somnolency,  as  a  symptom  of  basilar  meningitis,  is  of  par- 
ticular value  for  the  diagnosis  of  the  initial  period  of  this  disease, 
in  case  it  be  not  accompanied  by  fever,  because  in  the  contrary 
event  it  may  be  the  direct  consequence  of  elevated  temperature  of 
whatever  nature.  Thus,  sonuiolence  is  indicative  of  a  cerebral 
lesion  only  if  its  degree  does  not  correspond  altogether  to  the 
degree  of  fever,  or  if  somnolency  a])pears  after  the  fever  stops, 
that  is,  in  the  period  of  recovery  from  any  febrile  disease. 

Furthermore  characteristic  are  the  symptoms  on  the  part  of 
the  digestive  organs;  the  tongue  is  quite  clean  (in  gastric  vomit- 
ing it  is  usually  thickly-coated)  and  from  the  very  first  day  of 
the  disease  constipation  sets  in,  which  is  especially  interesting  re- 
garding the  diagnosis;  the  abdomen,  despite  the  persistent  con- 
stipation of  many  days'  duration,  not  only  does  not  distend,  but 
even  becomes  softer  with  each  day  and  shaUon'cr  and  tozmrd  the 
end  of  the  week  it  becomes  retracted,  "boat-shaped."  (We  do  not 
know  how  to  explain  such  a  form  of  the  ab<lomen.  It  may  l>e 
partly  due  to  the  fact  that  the  child  from  the  very  beginning  of 
the  disease  does  not  eat  anything,  but  this  is  not  the  only  or  the 
chief  cause  of  the  retracted  abdomen.  It  is  also  impossible  to  ex- 
plain this  occurrence  by  spasm  of  the  bowels  or  of  the  abdominal 
musculature,  but  it  is  probable  that  the  chemistry  of  intestinal 
digestion  changes,  so  that  little  intestinal  gas  is  formed.) 

Constipation  is  a  quite  important  symptom  in  the  diagnosis 
of  meningitis,  first,  because  it  belongs  among  the  constant  evi- 
dences of  this  disease,  and,  secondly,  because  it  is  combined  with 
the  subsequent  sunken  abdomen,  which  is  usually  absent  in  catarrh 


i)isi:.\si-:s  OF  tiik  ni-.rx'ous  svs'n-:.\[  441 

of  the  sloniach  and  that  of  tlie  l>o\vcls.  also  in  typhoid,  that  is, 
in  those  (Hseases  with  wliieh  acute  hydrocephalus  is  most  often 
confused  in  its  initial  period. 

Constipation  is  comparatively  often  absent  durini;-  menin,t(iti,s 
in  nursling-s,  which  may  be  explained  by  the  constipation  in  men- 
ingitis depending  perhaps  on  irritation  of  the  splanchnic  nerve, 
and  by  the  inhibitory  nervous  system  in  small  children  generally 
being  in  poor  activity,  so  a  priori  one  would  not  expect 
meningitis  in  small  children  to  be  so  persistently  accompanied  by 
constipation  as  in  older  ones,  which  opinion  is  amply  confirmed 
by  observations.  Hut  the  diagnosis  is  aided  in  such  children  by 
the  gastric  vomiting  being  necessarily  accompanied  l)y  intestinal 
disorders  in  the  form  of  dyspepsia  or  watery  diarrhoea,  so  that 
if,  despite  the  repeated  vomiting  in  a  nursling  during  several  days 
(and  the  more  if  there  develops  an  inclination  to  coiisfipatioii.  or 
if  a  preceding  diarrhoea  stops),  then  this  fact  is  hii^lily  suspicious; 
moreover,  if  simultaneously  the  child  be  at  the  breast  and  any 
data  of  irritation  of  the  stomach  by  a  coarse  food  be  absent  from 
the  history,  then  there  can  be  no  doubt  of  the  meningeal  origin 
of  vomiting. 

Further  in  the  diagnosis  of  the  initial  period  of  vomiting, 
there  is  of  importance  the  course  of  the  temperature.  It  happens 
very  rarely  that  tubercular  infiammation  of  the  meninges  occurs 
with  normal  temperature,  or  with  fever  higher  than  39  degrees  C. 
(102.2  degrees  F.)  ;  usually  there  is  found  a  suhfchrilc  condition 
with  oscillations  from  37.8  degrees  C.  (100  degrees  F.)  up  to 
38.8  degrees  C.  (101.8  degrees  F.).  On  one  hand  such  a  tem- 
perature is  too  high  for  a  sim])le  dyspepsia  in  nurslings,  in  which 
there  is  no  fever ;  on  the  other  hand  it  is  too  low  for  typhoid.  I 
am  convinced  that  if  physicians  would  more  thoroughly  appre- 
ciate the  significance  of  the  temperature  then  confusion  between 
typhoid  and  meningitis  would  occur  less  frequently.  That  toward 
the  end  of  the  disease  the  temperature  in  meningitis  may  reach 
hyperthermic  degrees  (41  to  42  degrees  C. — or  105.8  to  107.6 
degrees  F.)  because  of  paralysis  of  the  regulatory  centers,  is  of 
no  special  value,  because  it  occurs  shortly  before  the  fatal  issue. 
One  must  also  note  that  normal  or  even  subnormal  tempera- 
ture  in   the  period   of  souiuoleucx  does  not  exclude   meningitis, 


442 


DISEASES    OF    THE    NERVOUS    SYSTEM 


although  such  appearance  is  much  oftener  met  with  during  false 
meningitis,  that  is,  during  so-called  hydrocephalus  due  to  anaemia 
or  cfidema  of  the  brain. 

The  pulse  may  in  the  first  days  of  the  disease  be  quickened, 
according  to  the  fever,  but  at  the  end  of  the  first  week,  and 
sometimes  even  earlier,  it  becomes  retarded  and  irregular.  The 
number  of  pulse-beats,  in  rare  cases  in  children  several  years  of 
age,  may  fall  to  fifty  or  sixty,  but  during  fever,  even  slight, 
ninety  beats  may  be  held  as  a  retardation,  because  in  children 
five  or  six  years  of  age  a  temperature  of  about  38.5  degrees  C. 
(101.3  degrees  F.)  is  usually  associated  with  a  pulse  of  about 
120,  and  in  nurslings  about  140,  so  that  in  the  latter  112  may  be 
boldly  held  as  a  retarded  pulse,  and  with  more  reason  in  that  the 
vagus,  as  a  nerve  inhibiting  the  heart,  in  them  acts  poorly,  so 
that  a  more  pronounced  retardation  cannot  be  expected  in  the 
period  of  deeper  somnolency.  Especially  after  convulsions  have 
appeared  the  pulse  becomes  accelerated  more  and  more,  reaching, 
before  death,  two  hundred  or  becoming  so  weak  and  frequent  that 
it  cannot  be  counted. 

As  to  the  irregularity  of  the  pulse,  the  same  is  manifested 
first  of  all  by  disproportion  of  the  strength  and  frequency  of  the 
pulsations,  then  by  slight  irregular  beats  due  to  the  sudden  stop- 
page of  heart-activity,  then  the  irregular  beats  become  more  con- 
.  stant.  The  most  insignificant  irregularities  cannot  be  noticed  by 
the  finger  counting  the  pulse,  but  they  are  easily  detected  by  the 
stethoscope,  because  the  organs  of  hearing  are  in  this  regard  more 
sensitive  than  those  of  touch. 

The  irregular  and  retarded  pulse  may  considerably  aid  the 
diagnosis  of  meningitis  only  when  simultaneously  there  are  other 
meningeal  symptoms,  for  instance,  apathy  or  somnolency ;  but, 
by  itself,  such  a  pulse  does  not  exhibit  anything  ominous,  as  it 
may  also  occur  without  meningeal  lesion,  for  instance,  in  con- 
valescents after  febrile  diseases,  in  anaemia  and  in  small  children 
during  sleep. 

With  the  beginning  of  the  second  week  of  the  disease  when 
the  vomiting  has  ceased  and  the  irregularity  of  the  pulse  and  the 
somnolency  are  expressed  more  or  less  decidedly,  then  some  new 
symptoms  appear  which  finally  clear  up  the  diagnosis :  deep 
sighing,  symptoms  on  the  part  of  the  eyes,  chewing  movements 


DISEASES    OF    THE    NERVdUS    SYSTEM  443 

'of  the  inferior  maxilla  and  automatic  uniform  movements  of  this 
•or  that  extremity  (most  often  the  child  begins  to  make  continuous 
movement  with  the  arm ;  he  lifts  the  same  to  the  head,  passes  it 
down  over  the  face  and  chest  to  the  abdomen,  again  raises  it  to 
the  forehead,  etc.,  for  half  an  hour  or  longer,  several  times  a 
•day),  also  symptoms  on  the  part  of  the  vasomotors.  Still  later 
contracture  of  the  neck,  general  convulsions  and  difiicult  degluti- 
tion  appear. 

The  respiration  is  normal  during  the  first  days,  but  in  the 
period  of  somnolency  there  are  at  times  deeper  sighings,  often 
followed  by  long  intervals  (as  if  the  child  forgets  to  breath,  as 
Barthez  and  Rilliet  express  it)  ;  sometimes  quiet  respiration  is 
interrupted  by  monotonous,  short  cries  (cri  hydrocephalique, 
of  Coindet)  ;  still  later  in  the  period  of  complete  somnolency  (the 
end  of  the  second  and  the  beginning  of  the  third  week)  the  respira- 
tion assumes  the  Cheyne- Stokes  character. 

The  eyes  exhibit  so  many  symptoms  characteristic  of  men- 
ingitis that  by  them  one  can  often  recognize  the  disease  froni  a 
distance.  First  of  all  there  is  the  immobile  stare,  which  symptom 
is  most  valuable  in  the  diagnosis  of  meningitis  in  small  children 
in  whom  it  appears  quite  early  (the  end  of  the  first  week)  ;  the 
•child  rarely  winks,  the  eye-lids  are  widely  open,  and  the  eyes 
look  immovably  into  distance ;  he  does  not  fix  upon  any  thing 
brought  near,  and  probably  does  not  see  well  as  he  does  not  wink 
upon  the  approach  of  the  finger  to  the  eye ;  the  pupils  are  wide 
and  at  the  same  time  slowly  react  to  light.  Not  infrequently 
oscillatory  vibrations  of  the  pupils  are  noticed,  that  is,  under 
the  influence  of  light  the  pupil  contracts  for  a  short  time,  but 
immediately  dilates  again,  notwithstanding  the  lasting  action  of 
the  light.  As  a  good  diagnostic  method  for  the  distinction  of 
acute  hydrocephalus  from  all  similar  diseases  Parrot  points  out 
that  considerable  dilatation  of  the  pupil  may  be  caused  by  pricking 
the  skin  of  the  abdomen.  I  have  had  the  opportunity  to  convince 
myself  that  this  sign  is  constantly  met  with  in  the  period  of  in- 
complete somnolence,  but  a  pricking  of  the  skin  of  the  abdomen 
alone  is  unnecessary  for  this  purpose,  any  painful  irritation  being 
sufficient.  But  a  question  arises  here ;  how  especially  cliaracter- 
istic  is  this  symptom  of  meningitis?  and  does  it  not  also  occur  dur- 
ing other  diseases  ending  with  somnolence?  The  decision  of  this 
question  requires  further  observations. 


444  DISEASES    OF    THE    NERVOUS    SYSTEM 

Then  again  we  have  two  more  symptoms  on  the  ])art  of  the- 
eyes;  strabismus  (appears  much  later  than  the  immobile  stare) 
and  changes  of  the  fundus  of  the  eye.  If  the  ophthalmoscope- 
shows  the  presence  of  tubercles  on  the  choroid,  then  the  diagnosis 
of  miliary  tuberculosis  is  undoubted,  but  the  trouble  is  that  tuber- 
cles of  the  choroid  occur  very  seldom,  oftener  oedematous  papilla 
being  found,  but  this  symptom  is  not  altogether  pathognomonic- 
of  acute  hydrocephalus ;  it  denotes  only  a  hindred  blood  circu- 
lation and  increased  blood  pressure  in  the  cavity  of  the  skulls 
which  may  depend  also  upon  a  brain  tumor,  and  on  other  causes 
as  well. 

Symptoms  denoting  vasomotor  disturbances  appear  compara- 
tively late.  Two  kinds  of  appearances  are  here  included  : — first,, 
quick  change  in  the  color  of  the  face,  and,  second.  Trousseau's 
sj>ots. 

In  the  first  period  of  tubercular  meningitis  the  face  is  pale,, 
but  vasomotor  disturbances  occurring  in  the  period  of  (|uite  deep 
somnolence  sometimes  give  rise  to  the  sudden  development  of 
bright  redness  of  one  or  both  checks,  quickly  disappearing  again. 
Not  rarely  one  succeeds  in  ])ri>ducing  such  a  ])lay  of  colors  arti- 
ficially ;  it  is  only  necessary  to  trouble  the  child  by  something. 

To  make  Trousseau's  spots  appear  one  has  to  pass  the  finger 
in  a  line  over  the  skin  of  the  trunk,  or  employ  some  blunt  in- 
strument, moderately  pressing.  After  one-fourth  to  one-half 
minute  a  brig-ht  red  stripe  is  seen  on  the  place  of  the  line,  which 
remains  for  quite  a  long  time  gradually  disappearing  from  the 
margins.  Although  these  spots  constantly  occur  in  the  late  period 
of  tubercular  meningitis,  their  diagnostic  meaning  is  not  very 
great,  because  they  are  also  met  with  in  other  diseases,  for  in- 
stance, in  typhoid. 

Contracture  of  the  neck  also  belongs  to  the  quite  constant, 
but  late,  symptoms  of  tubercular  meningitis.  It  may  be  of  value- 
for  the  differential  diagnosis  from  typhoid  only  because  it  is  ac- 
companied by  a  comparatively  low  temperature,  while  l)v  high, 
ones  in  t3'phoid  (104  degrees  F.  and  more). 

In  the  presence  of  contracture  of  the  neck  the  passive  flexion 
of  the  head  is  always  very  painful,  producing  a  reaction  on  the 
part  of  the  patient  in  the  form  of  a  cry  or  painful  expression  of 
the  face,  even  in  the  period  of  very  deep  somnolence,  when,  for 


DISEASES    OF    THE    NERVOUS    SYSTEM  445 

instance,  the  pricks  of  a  needle  are  evidently  not  felt.  As  the 
recumbent  posture  on  the  back  is  associated  with  some  pressure 
of  the  pillows  upon  the  contracted  neck  in  Ixinding  the  head, 
therefore,  the  child,  despite  the  somnolency,  instinctively  assumes 
a  position  on  the  side,  and  for  preserving  the  balance  flexes  the 
legs  upon  the  thighs,  that  is,  he  lies  on  the  side  as  if  rolling; 
such  a  position  being  known  under  the  name  of  "chien  a  fusil,'' 
is  very  peculiar  of  tubercular  meningitis  (in  typhoid  for  instance, 
the  patients  remain  on  the  back  most  all  the  time). 

There  is  also  characteristic,  in  the  general  appearance  of  a 
patient  suffering  with  meningitis,  the  considerable  wasting  of  the 
body  reaching  in  this  disease  the  highest  degrees  in  a  compara- 
tively short  period ;  in  the  course  of  about  two  weeks  the  patient 
exhibits  only  skin  and  bones,  so  to  say,  that  is,  such  a  wasting  as 
occurs  in  typhoid  much  later. 

General  convulsions  by  themselves  exhibit  nothing  typical  of 
meningitis.  One  should  bear  in  mind  that,  notwithstanding  the 
•complete  absence  of  a  focal  lesion  of  the  brain,  they  may  never- 
theless be  unilateral,  leaving  later  on  circumscribed  paralyses. 
Almost  never  does  eclampsia  set  in  from  the  very  first  of  the 
disease,  but  usually  three  or  four  days  before  death.  According 
to  Barthez  and  Rilliet  if  the  convulsions  appear  at  the  onset,  being 
especially  persistent,  then  they  always  denote  the  presence  of  large 
tubercles  in  the  brain. 

The  parents  often  question  the  physician  whether  the  child 
will  live  long?  If  his  torture  will  soon  end?  To  determine  the 
time  of  death  is  generally  a  hard  task,  and  in  tubercular  men- 
ingitis the  more  so  as  its  duration  varies  greatly ;  but  approximate- 
ly one  may  be  guided  by  the  following  circumstances : — In  the 
majority  of  cases  acute  hydrocephalus  (tubercular  or  simple,  im- 
materially) lasts  two  to  three  weeks.  As  long  as  the  pulse  re- 
mains retarded,  a  very  quick  death  should  not  be  expected,  even 
if  the  somnolence  be  decidedly  developed ;  if  the  pulse  begins  to 
be  considerably  accelerated,  then  death  is  near,  and  if  it  reaches 
180  to  200  beats,  then  the  patient  will  hardly  survive  more  than 
twenty-four  or  thirty-six  hours.  The  impossibility  of  swallow- 
ing (not  only  during  the  convulsions,  but  constantly)  sets  in  not 
earlier  than  twenty-four  hours  before  the  fatal  event,  but  a  rat- 
tling, bubbling  respiration,  a  few  hours  before.     Especially  rapid 


446  DISEASES    OF    THE    NERVOUS    SYSTEM 

is  the  course  of  meningitis  when  it  develops  in  a  child  sufferings 
with  pronounced  tuberculosis.  According  to  Rilliet  and  Barthez- 
the  disease  in  such  cases  begins  directly  with  convulsions  followed' 
by  somnolence  and  other  evidences  of  the  last  stage. 

Tubercular  meningitis  in  its  different  periods  may  be  similar- 
to  many  diseases.  In  all  doubtful  cases  one  must  first  of  all  en- 
deavor to  decide  the  question  of  the  precursory  period  (that  is, 
if  there  were  corresponding  symptoms  in  any  given  case)  and  if 
the  child  has  an  hereditary  or  acquired  disposition  to  tuberculosis. 
To  make  a  positive  diagnosis  of  tubercular  meningitis  in  the 
absence  of  the  above-mentioned  etiological  conditions,  one  must 
obtain  considerably  more  aetiplogical  information  than  is  required' 
when  the  patient  himself,  or  his  near  relatives,  have  suffered  from» 
this  or  that  form  of  tuberculosis. 

It  is  impossible  to  recognize  approaching  tubercular  meningi- 
tis in  the  prodromal  period,  because  at  this  time  there  are  no 
characteristic  symptoms.  That  the  child  without  any  known  cause 
loses  his  appetite  and  grows  thin  and  pale  does  not  prove  any- 
thing, as  such  symptoms  also  occur  in  anaemia,  mild  stomach 
catarrh  or  with  intestinal  worms.  The  condition  becomes  more 
suspicious  if  besides  this  the  child  manifests  symptoms  of  brain 
irritation ;  if  he  complains  of  dizziness,  becomes  frightened  in 
sleep,  or  grinds  the  teeth,  such  symptoms  previously  having  been- 
absent. 

If  the  prodromal  period  runs  with  considerable  fever  then 
typhoid  may  be  diagnosed  (see  the  diagnosis  of  typhoid  from  acute- 
miliary  tuberculosis). 

In  the  first  period  when  the  main  symptoms  consist  in. 
vomiting,  headache,  apathy  and  constipation,  the  question  may 
arise  concerning  a  stomach  catarrh,  a  beginning  typhoid,  and  brain- 
congestion. 

About  the  distinction  of  stomach  vomiting  from  the  cerebral 
form  see  page  155,  here  we  only  add  the  following  : — In  a  nursling, 
a  beginning  meningitis  is  often  mistaken  for  dyspepsia,  because 
in  both  cases,  besides  vomiting,  restlessness  of  the  child  is  alsO' 
observed. 

Opposed  to  dyspepsia  there  is : 

First,  elevation  of  .temperature,  usually  accompanying  a  be- 
ginning meningitis,  especially  in  small  children. 


DISEASES  OF  THE  nm=:rvous  system  447 

Second,  the  absence  of  dyspeptic  stools.  This  symptom  is 
extremely  important,  if  present ;  but  as  diarrhoea  in  small  children 
may  also  be  met  with  in  meningitis,  then  one  should  remember 
that  a  contrary  conclusion  on  this  ground  cannot  be  made. 

Third,  the  persistency  of  voiniting.  Vomiting  in  dyspepsia 
usually  stops  very  soon  if  the  diet  be  regulated  (for  instance, 
forbidding  cow's  milk)  and  if  corrective  remedies  be  administered 
(bismuth,  cerium  oxalate,  small  doses  of  calomel)  ;  while  in  men- 
ingeal vomiting  it  is  characteristic  that  it  lasts  persistently,  not- 
withstanding the  food  of  the  child  is  most  correct  (even  the 
mother's  milk)  and  that  it  does  not  yield  to  drugs.  It  is  still 
more  typical  if  no  diet  error  he  found  to  he  the  cause  of  vomiting, 
that  is,  if  vomiting  appears  in  a  child  under  the  same  food  which 
he  previously  took  very  well. 

Fourth,  the  character  of  the  cry.  In  dyspepsia  the  cry  is 
violent,  but  appears  in  attacks,  that  is,  appears  suddenly  and  as 
suddenly  also  disappears,  while  in  meningitis  the  child  cries  per- 
haps not  so  violently,  but  longer;  he  is  restless  day  and  night. 
Cry  due  to  colics,  like  that  of  dyspepsia,  occurs  oftener  the 
younger  the  child,  mostly  from  one  to  three  months ;  meningitis, 
on  the  contrary,  occurs  after  six  months. 

Fifth,  the  further  course.  A  few  days  after  the  appearance 
of  meningeal  vomiting  the  child  becomes  somnolent  and  later 
on  other  meningeal  symptoms  develop,  of  which  a  tense,  some- 
times even  protruded,  fontanelle,  immobile  stare  and  sucking 
movements  of  the  lips  during  sleep,  usually  occur  earlier  than 
the  eclamptic  convulsions,  complete  somnolence  and  the  contracted 
neck. 

Still  greater  similarity  to  a  beginning  acute  hydrocephalus 
is  sometimes  presented  by  cases  of  subacute  gastritis  in  older 
children.  This  disease  pursues  a  course  either  with  normal,  or 
slightly  elevated,  temperature,  being  sometimes  characterized  by 
the  same  symptoms  as  in  a  beginning  meningitis,  that  is,  by  vomit- 
ing, mild  headache,  apathy,  constipation  and  even  irregular  and 
retarded  pulse.  Such  forms  of  gastritis,  examples  of  which  may 
be  found,  for  instance,  in  Henoch's  Text-book  (third  edition,  page 
297),  in  Rilliet  and  Barthez  (Volume  II.,  page  37),  as  well  as 
in  the  first  volume  of  the  author's  Lectures  on  Infectious  Diseases 
in  Childhood    (page  231),  oftener  occur  in  children  from  four 


448  DISEASES    OF    THE    NERVOUS    SYSTEM 

to  seven  years  of  age.  The  differential  diagnosis  between  gas- 
tritis and  meningitis  cannot  always  be  established  in  such  in- 
stances upon  a  consideration  of  the  symptoms  alone ;  and  there- 
fore the  etiological  features,  as  well  as  the  further  course  and 
the  results  of  therapy,  become  of  great  importance.  False  men- 
ingitis (that  is,  gastritis)  may  be  suspected  in  case  the  cerebral 
symptoms  appear  in  a  previously  healthy  child  after  some  coarse 
faults  in  diet,  or  after  a  food  to  which  the  child  is  not  entirely 
accustomed,  as  well  as  where  we  have  to  deal  with  a  child  who 
has  been  starved  for  a  long  time,  or  is  convalescent  from  an  acute 
febrile  disease  and  the  rapidly  increasing  appetite  is  incautiously 
satiated.  On  the  contrary,  gastritis  is  unfavorable  if  there  are 
no  causes  therefor  on  the  part  of  the  diet.  In  any  event  doubt 
cannot  last  long,  as  the  cerebral  symptoms  in  gastritis  disappear 
in  a  few  days,  increasing,  however,  in  meningitis. 

Concerning  the  therai)y.  a  laxative  may  serve  as  a  determi- 
nant, let  it  be  calomel  or  something  else.  Cerebral  symptoms  due 
to  meningitis  will  either  remain  unchanged  after  the  bowels  are 
moved,  or  changed  very  little ;  while  in  the  case  of  gastritis  a 
rapid  amelioration  follows.  Hence  the  rule  that  if  the  child 
manifests  symptoms  which  resemble  the  first  period  of  tuber- 
cular meningitis,  then,  first,  one  should  be  conservative  as  to 
the  exast  diagnosis,  and,  second,  a  laxative  should  be  administered 
first  of  all. 

It  may  be  said  that  in  cases  of  gastritis  no  complete  similarity 
to  a  beginning  meningitis  will  be  present,  as  some  of  the  symptoms 
fail  to  show ;  either  the  retarded  pulse  is  absent,  or  apathy  is  not 
noticeable,  and  sometimes  even  vomiting  does  not  occur. 

Again  it  is  easier  to  recognize  gastritis  accompanied  by  men- 
ingeal symptoms  when  there  are  symptoms  especially  peculiar  of 
gastritis,  as  jaundice,  or,  at  least  yelloivishncss  of  the  conjunc- 
tiva, thickly-coated  tongue,  repulsive  odor  from  the  mouth,  dis- 
tension and  slight  painfulness  in  the  epigastrium  upon  pressure 
over  the  same  and,  finally,  herpes  labialis,  which  almost  never 
occurs  in  cerebro-spinal  meningitis,  but  very  often  where  there  is 
a  foul  stomach. 

Opposed  to  gastritis  and  in  favor  of  meningitis  there  may 
be  pointed  out,  in  Henoch's  opinion,  irregular  and  at  the  same 
time  retarded  pulse,  while  an  irregularity  alone  without  retarda- 


DISEASES    OF    THE    XERVOL'S    SYSTEM  ^i) 

tion  is  of  no  i;reat  tliai^nostic  nuIuc  (in  our  ojjinion.  even  tlie 
sinniltaneous  existence  of  l)oth  these  signs  does  not  decide  the 
question). 

Some  autliors  claim  that  the  picture  of  a  l)e|L;inning  menin.^i- 
tis  may  be  produced  by  intestinal  zvoniis.  In  the  case,  for  in- 
stance, of  Saint  Goglimelh,  a  boy  aged  nine  years  suddenly  be- 
came sick  with  chills  {38.5  degrees  C. — 10 1.3  degrees  F.)  and 
repeated  biliary  vomiting;  afterwards  neck-contracture  appeared, 
together  with  convergent  strabismus,  grinding  of  the  teeth,  out- 
crying and  a  half-comatose  condition.  After  the  ascarides  (about 
one  hundred)  came  away  (in  three  days),  the  child  promptly  re- 
cove  red '^ 

In  literature  such  cases  are  described  quite  frequently,  and 
there  is  nothing  improbable  in  holding  that  irritation  of  the  bowels 
by  worms  may  cause  a  reflex  action  on  the  vasomotor  system  of 
the  brain,  thus  producing  circulatory  disorders  within  the  cranium. 
Much  oftener  one  will  see  the  elimination  of  worms  (ascarides; 
at  the  onset  of  meningitis,  but  the  anthelmintic  treatment  and 
effect  does  not  influence  in  consequence  the  course  of  the  brain 
disease. 

The  same  may  also  be  said  regarding  dentition.  The  latter 
very  often  takes  place  during  meningitis,  but  this  process  hardlv 
ever  causes  the  complex  of  symptoms  of  acute  hydrocephalus  in 
the  form  of  somnolence,  retarded  pulse,  contracted  neck,  etc.  It 
is  true  that  in  children  disposed  to  convulsions  dentition  not  very 
seldom  is  accompanied  by  eclampsia,  but  in  such  instances  the 
picture  of  the  disease  does  not  resemble  tubercular  meningitis 
very  clearly. 

The  dependence  of  the  cerebral  symptoms  upon  intestinal 
worms  or  teeth  is  acknowdedged  only  when  all  symptoms  rapidly 
disappear  soon  after  the  removal  of  the  cause  (expulsion  of 
ascarides,  appearance  of  the  tooth).  Such  men  of  experience  as 
Henoch  and  Cadet  de  Gassicourt,  among  others,  admit  the  pos- 
sibility of  cerebral  hypenemia?  simulating  meningitis  under  the 
influence  of  dentition. 

If  tubercular  meningitis  is  the  final  stage  of  acute  miliary 
tuberculosis,  being  in  such  case  accompanied  by  considerable 
fever,  at  least  in  the  beginning,  then  the  question  of  typhoid  arises. 


*Vratch,"  1887,  page  605. 


450  DISEASES    OF    THE    NERVOUS    SYSTEM 

the  more  so  inasmuch  as  typhoid  also  may  be  accompanied  by 
various  cerebral  symptoms  which  simulate  meningitis.  Regarding 
the  diagnosis  of  these  typhoidal  forms  of  meningitis  from  typhoid 
proper,  we  shall  speak  in  the  section  on  the  latter,  here  men- 
tioning only  that  typical  cases  of  tubercular  meningitis  dififer 
from  typhoid  very  markedly  in  the  temperature.  Nervous  symp- 
toms (somnolency,  contracture  of  the  neck,  headache,  etc.)  in 
meningitis  are  accompanied  by  nearly  normal  temperature  (usual- 
ly below  39  degrees  C. — 102.2  degrees  F.),  while  in  typhoid 
fever  symptoms  manifesting  a  profound  infection  are  coincident 
with  considerable  fever  (about  40  degrees  C. — 104  degrees  F.). 
Of  separate  symptoms  pro  meningitis  and  contra  typhoid  we 
would  indicate  the  retarded  and  irregular  pulse  (in  typhoid  the 
pulse  is  frequently  also  retarded,  but  it  remains  regular),  re- 
tracted alxlomen,  despite  the  constipation  (in  typhoid  the  abdomen 
is  somewhat  distended  and  diarrhoea  is  often  present),  paralyses 
of  the  facial  and  eye  muscles,  automatic  movements  of  this  or  that 
limb,   wide,   non-reacting  pupils,   vacant  stare. 

Great  likeness  to  the  initial  period  of  meningitis  may  be 
presented  by  cases  of  otitis  media.  As  even  older  children  do 
not  always  complain  of  earache,  this  disease  is  therefor  often 
overlooked.  As  in  meningitis,  there  may  be  elevation  of  tem- 
perature, headache,  vomiting,  blunted  consciousness,  sudden  cries, 
restlessness  and  even  convulsions.  In  order  not  to  fall  into  an 
error  one  must  adhere  to  the  rule  of  examining  the  ears  of  every 
child  presenting  symptoms  of  brain  irritation.  This  is  especially 
needful  in  a  case  where  there  is  some  ground  for  suspecting  ear- 
afifection,  for  instance,  when  the  patient  has  snuffles  or  sore- 
throat,  or  is  sick  with  scarlet  fever,  measles,  small-pox  or  pneu- 
monia. For  diagnostic  purposes  Troltch  recommends,  in  such 
cases,  the  resort  to  Politzer  inflation  of  the  ears.  If  the  general 
condition  improves  considerably  after  that,  then  the  existence 
of  exudative  otitis  can  scarcely  be  doubted.  Valuable  results  may 
also  be  obtained  from  palpation  of  the  ears  (pain  upon  pressure 
over  the  tragus,  or  mastoid  process,  swollen  glands  just  behind 
the  external  ear,  or  in  the  region  of  the  parotid),  and  in  older 
children  examination  of  the  sense  of  hearing.  With  the  appear- 
ance of  discharge  from  the  ear  all  cerebral  symptoms  rapidly  dis- 
appear. 


DISEASES    OF    THE    NERVOUS    SYSTEM  45 1 

Finally,  symptoms  of  meningitis  may  be  caused  by  cerebral 
hyperemia,  occurring  in  children  under  the  influence  of  forced 
mental  exercises,  insolation,  trauma  and  alcoholic  drinks.  Under 
the  influence  of  this  or  that  cause  the  child  complains  of  headache, 
vomiting  sets  in,  the  temperature  rises  somewhat,  somnolence  ap- 
pears, as  well  as  retardation  and  irregularity  of  the  pulse  and 
even  contracture  of  the  neck  ;  in  a  word,  everything  is  as  in  the 
onset  of  meningitis,  with  only  the  difference  that  all  these  symp- 
toms rapidly  disappear  after  a  few  days,  and  the  child  recovers. 

Similar  cases  also  occur  during  some  acute  infectious  diseases 
(pneumonia  crouposa,  influenza,  typhoid,  etc.). 

It  is  easy  sometimes  to  mistake  for  tubercular  meningitis  cases 
of  false  meningitis  of  hysterical  origin,  to  which  we  shall  refer 
in  discussing  false  meningitis. 

In  the  second  period  of  meningitis,  when  all  symptoms  of 
brain  compression  (somnolence,  paralytic  and  convulsive  evi- 
dences, non-reacting  pupils,  etc.)  are  developed  markedly,  when, 
in  a  word,  the  existence  of  the  cerebral  disease  is  beyond  doubt, 
then  the  diagnosis  may  be  difficult  only  in  regard  to  other  cerebral 
lesions  as : — 

(i)  Acute  hydrocephalus. 

(2)  Meningitis  arising  in  the  vicinity  of  some  new-growth, 
as  solitary  tubercles,  gummata,  sclerosis   (Cadet  de  Gassicourt). 

(3)  Acute  purulent  meningitis. 

(4)  Anaemia  and  oedema  of  the  brain. 

(5)  Passive  hypersemia  and  thrombosis  of  the  sinuses. 

In  all  these  cases  the  diagnosis  is  based  not  so  much  on 
separate  symptoms,  as  on  the  history  and  the  course. 

But  before  speaking  about  each  process  separately  we  offer 
a  few  words  about  lumbar  puncture,  recommended  by  Quincke, 
in  189 1,  as  a  diagnostic  and  therapeutic  remedy  in  some  cerebral 
diseases.  The  technique  of  the  operation  consists  in  introducing 
the  needle  of  a  Pravatz'  hypodermic  syringe  along  the  median  line 
between  the  spinous  processes  of  the  third  and  fourth  vertebrae, 
while,  for  the  sake  of  greater  convenience  the  patient  should  lie  on 
the  right  side  with  the  spine  bent  and  the  thighs  abducted  uptin  the 
abdomen.  The  needle  is  introduced,  in  small  children,  two  centi- 
meters deep,  in  older  ones  four  centimeters.  The  needle  thus 
enters  the  subarachnoidal  space  and  the  cerebro-spinal  fluid  im- 


452  DISEASES    OF    THE    NERVOUS    SYSTEM 

niecliatelv  begins  to  flow,  which  fluid  may  be  accumulated,  accord- 
ing to  the  case,  in  quantities  of  from  five  to  sixty  grams,  with- 
out resorting  to  suction.  [TremoHeres  recommends  for  Quincke's 
hunbar  puncture  a  platino-iricHum  needle,  on  account  of  its 
superior  flexibility.  In  children  the  jnmcture  should  be  made 
in  the  middle  line  rather  than  laterally,  between  the  fourth  and 
fifth  lumbar  vertebrae.  A  properly  carried  out  lumbar  puncture 
ought  always  to  yield  some  fluid.  If  only  a  small  quantity  is 
withdrawn,  without  aspiration,  the  patient  being  kept  horizontal, 
no  danger  need  be  apprehended  :  at  the  worst,  some  \rdm  in  one 
or  the  other  thigh,  if  a  nerve  be  touched  during  the  operation, 
and  slight  headache,  may  be  anticipated. 

Lumbar  puncture  is  sustained  better  liy  patients  sufl'ering 
from  tubercular  meningitis  than  by  others,  and  its  two-fold  action 
in  lowering  the  intra-spinal  pressure,  and  diminishing  the  amount 
of  toxine  in  the  nervous  system,  often  has  at  least  a  palliative 
efifect*.— K.\Kr.K  |  The  fluid  is  examined  microscopically  for  diag- 
nostic purposes  and  eventually  decisive  results  may  be  obtained. 
For  instance,  a  great  quantity  of  pus  corpuscles  denote  purulent 
meningitis ;  in  tubercular  meningitis  one  sometimes  succeeds  in 
finding  tubercle  bacilli ;  in  cerebro-spinal  meningitis  the  intracel- 
lular diplococcus  (memingococcus  intracellularis  s.  diplococcus 
intracellularis  meningitis,  of  Weichselbaum  )  is  often  found  :  in 
cases  of  meningitis  developing  in  typhoid  or  in  pneumonia  the 
typhoid  bacillus  or  pneumococcus  has  been  observed,  etc.  As  to 
the  therapeutic  importance  of  lumbar  punction  this  is  inconsider- 
able. In  those  cases  where  the  communication  between  the  cavi- 
ties of  the  ventricles  and  the  subarachnoid  space  of  the  spine  is 
not  impaired,  then  lumbar  puncture,  as  a  palliative  remedy,  may 
improve  the  headache  and  thus  give  rest  to  the  patient  for  a  few 
hours. 

(i)SiMPLE  ACUTE  HYDROCEPHALUS  is  characterized  by  the 
same  symptoms,  and  in  many  cases  by  the  same  course,  as  in  the 
tubercular  form.  The  single  symptom  which  is  especially  peculiar 
to  tubercular  meningitis,  namely,  the  presence  of  tubercles  on  the 
fundus  of  the  eye,  is  more  of  theoretical  interest,  as  it  occurs  very 
rarelv. 


^Gazette  des  Hospitaux,  Nov.  "th  and  Nov.   loth    (Quoted  from   The 
Scottish  Med.  and  Surg.  Journal,  Febr.,  1904,  p.  165). 


DISEASES    OF    THE    NERVOUS    SYSTEM  453 

A  simple  serous  incningitis  may  be  supposed  ouly  if  the  cliil.l 
is  under  two  years  of  age ;  if  previously  to  the  meningitis  he  was 
entirely  well,  did  not  manifest  symptoms  of  the  precursory  period  . 
if  no  information  concerning  tuberculosis  is  given  in  the  histor\- 
and,  finally,  if  the  disease  ends  with  complete  recovery. 

In  some  cases  the  diagnosis  of  non-tubercular  acute  hvdro- 
cephalus  is  assisted  by  peculiarities  of  its  course.  As  a  matter  of 
fact,  children  are  met  with  in  seemingly  perfect  health,  with  gornl 
nutrition,  and  without  hereditary  disposition  to  tuberculosis,  who 
are  prone  to  cerebral  congestion.  Beginning  with  the  fourth  to 
the  sixth  month  of  life,  with  more  or  less  prolonged  intervals, 
they  are  attacked  by  eclamptic  convulsions  and  at  the  same  time 
with  vomiting  and  fever.  Such  fits  are  repeated  once  or  twice 
a  month,  but  each  time  pass  away  leaving  no  trace,  until,  finally, 
after  some  such  attack,  a  definite  meningitis  supervenes.  It 
is  especially  easy  to  make  a  diagnosis  of  simple  hydrocephalus 
in  cases  of  protracted  course,  when  the  meningitis  has  continued 
longer  than  one  month.  Sometimes  a  slowly-developing  hydro- 
cephalus becomes  a  chronic  hydrocephalus  '"  rnds  with  complete 
recovery. 

(2)  Circumscribed  meningitis  in  die  area  of  a  new  growth 
has  no  peculiarities  in  its  course.  Cadet  de  Gassicourt  includes 
in  this  class  all.  cases  of  meningitis  ending  with  recovery,  that 
is.  the  diagnosis  is  made,  so  to  say,  post-date.  Cadet  de  Gassi- 
court is  in  doubt  regarding  the  existence  of  an  idiopathic  non- 
tubercular  meningitis,  that  is,  of  a  simple  acute  hydrocephalus 
which  also  sometimes  ends  with  recovery. 

(3)  For  the  diagnosis  of  acute  purulent  meningitis  see 
the  next  section. 

(4)  Under  the  name  of  aiuciiiia  of  the  brain,  or  iivdro- 
cephaloid,  we  imderstand  a  symptom-complex  which  charat:- 
terizes  a  cerebral  lesion  in  children  exhausted  by  severe  forms 
of  diarrhoea.  The  anatomical  features  of  this  lesion  may  be  re- 
ferred to  the  arteries  becoming  empt}-  and  the  over-filling  of  the 
veins  because  of  the  weak  activity  of  the  heart ;  to  the  oedema 
of  the  brain ;  and  partly  to  dropsy  of  the  ventricles,  due  to  the 
disturbed  blood-circulation  in  the  brain,  and  to  the  atrophy  of  the 
brain  because  of  exhaustion  (hydrocephalus  ex  vacuo). 


454  DISEASES    OF    THE    NERVOUS    SYSTEM 

Hydrocephaloid  is  met  with  in  both  acute  and  subacute  forms, 
differing-  from  each  other  by  the  rapidity  of  development  of  symp- 
toms. The  acute  form  pecuHar  to  nurshngs  appears  as  a  sequel 
to  infantile  cholera,  while  the  subacute  form  occurs  in  children 
of  about  two  years  and  older  as  the  result  of  a  chronic  diarrhoea. 

In  the  former  case,  several  days  after  the  persistent  vomit- 
ing and  diarrhoea,  there  sets  in  first  of  all,  symptoms  of  irritation 
of  the  brain  (restlessness,  sleeplessness,  constant  rubbing  of  the 
head  upon  the  pillow),  collapse  quickly  comes  on,  and  simultan- 
eously there  are  symptoms  of  depression  of  the  brain,  denoted  by 
a  verv  small  and  frequent  pulse,  sunken  eyes  and  depressed  fon- 
tanelle.  The  child  becomes  somnolent  and  frequently  exhibits 
local  (contracture  of  the  neck  and  the  limbs)  or  general  con- 
vulsions and.  finally,  dies  in  somnolency  with  symptoms  of  com- 
plete exhaustion.  The  whole  disease  lasts  from  five  to  seven 
days. 

The  diagnosis  from  meningitis  is  based  upon  the  history 
(the  disease  started  with  vomiting  and  abundant  watery  diar- 
rhoea), appearances  of  collapse  (depressed  fontanelle,  general  ex- 
haustion, subnormal  temperature)  and  the  velocity  of  the  course. 

The  subacute  form  of  hydrocephaloid  develops  gradually, 
being,  therefore,  more  like  tubercular  meningitis  than  the  preced- 
ing form.  The  child  suffers  from  diarrhoea  for  several  weeks,  he 
has  become  very  thin,  so  that  the  skin  may  everywhere  be  pinched 
into  folds,  and  the  feet  and  the  eye-lids  often  show  ccdeiiiatous 
szuelling;  he  becomes  irritable,  suffers  from  sleeplessness,  shud- 
ders upon  hearing  a  marked  noise ;  in  general  he  represents  symp- 
toms of  irritation  of  the  brain.  Sometimes  even  vomiting  appears, 
but  the  pulse  becomes  neither  retarded  nor  irregular  even  in  the 
case  where  a  few  days  later  drowsiness  appears,  and,  still  later, 
a  complete  somnolency  sets  in  with  wide,  faintly  reacting  pupils, 
but  all  the  time  the  pulse  remains  small  and  frequent.  In  the 
period  of  somnolency  there  may  be  contracture  of  the  neck  or 
general  convulsions;  Trousseau  spots,  etc. ;  in  ,a  word,  a  picture 
is  obtained  most  resembling  the  late  period  of  tubercular  meningi- 
tis. Nevertheless,  the  diagnosis  is,  in  the  great  majority  of  cases, 
not  difficult  if  only  it  is  known  from  the  history  that  the  child 
suffered  from  chronic  diarrhoea,  which  caused  severe  wasting. 


Disi-:.\sE.s  OF  Till-:   .\i:r\()L's  system 


455 


(  )f  llio  various  syniplonis  whicli  may  Ik-  of  avail  tor  the  (liti'cr- 
ential  dias^nosis  of  hydrocephaloid  from  aculu  hydroci-'plialus,  the 
followiiiii'  should  he  hornc  iu  mind: — 


Flydrocrplialoid. 

The  temperature  is    below     the 
normal   (95-9  to  97.7  degrees  F.). 


The  pulse  is  always  small,  fre- 
quent and  feeble,  but  regular. 


I'oiiiitiiig  often  absent. 


.Lute  hydrocepJmUis. 

ihe  temperature  is  subfebrile 
(100  to  100.7  degrees  F.),  or  feb- 
rile. 

At  the  onset  retarded,  then  ac- 
celerated, but  in  both  cases  irregu- 
lar; liefore  death  very  frequent, 
llinad-likc. 

Always  in  the  beginning  of  the 
disease  and  usua'ly  repeated. 


Diarrha-a.  which  had  existed  be- 
fore the  disease,  lasts  also  in  the 
period  of  development  of  cerebral 
symptoms  and  stops  only  shortly 
before  death. 

The  picture  of  general  exhaus- 
tion not  infrequently  is  accompa- 
nied by  ccdcnia  of  the  feet  and 
face   (Widerhofer ). 

The  foiitanellc  sinks. 


Absence   of   paralyses    of    facial 
muscles. 


Constipation  almost  always  from 
the  first  days  of  the  appearance  of 
the  meningeal  symptoms;  if  there 
had  been  diarrhoea  then  this  usual- 
ly stops. 

Qidema  is  absent  even  when 
there  is  severe  wasting. 


The  fontanellc  is  protruding  and 
tense. 

Paralyses  occur  not  infre(|uenily. 


(5)  P.vssiVE  HYPER.EMiA  OF  THE  r.R.MX.  accompanied  by 
grave  cerehral  symptoms,  most  often  occurs  during  whooping- 
cough  in  small  children.  An  interesting  case  of  such  a  kind  is 
given  by  Henoch'''. 

Under  the  influence  of  violent  attacks  of  whooping-cough  in 
a  child  eclamptic  fits  began  to  appear,  and  then  gradually  other 
symptoms  also  developed  in  tlie  form  of  strabismus,  distant  l(X>k, 
sucking  movements  with  the  lips,  somnolence,  contracture  of  the 
neck  and  extremities.  After  twenty  ilavs  death  in  a  soporous 
condition.  I'^or  the  completeness  of  similarity  fever  (  38.4  to  39.2 
degrees  C. —  loi.i  to  102.5  degrees  F.)  due  t<~>  broncho-pneumonia, 
appeared  eleven  days  before  the  fatal  event.  Henoch  diagnosed 
tubercular   meningitis   and   made   a   mistake.     The   ])ost   mortem 


*Text-book,  third  German  edition,  page  .425. 


456  DISEASES    OF    THE    XERVOUS    SYSTEM 

showed  only  a  marked  oedematous  hypersemia  of  the  brain  and 
its  membranes  caused  by  whooping-cough  paroxysms  and  bron- 
cho-pneuinonia. 

Such  a  cause  of  cerebral  s}mptoms  may  then  only  be  sus- 
pected if  accompanied  by  some  other  signs  of  weakened  heart 
activity,  as  cyanosis  of  the  face,  coolness  and,  ])erhaps,  cfidema  of 
the  extremities,  and  extremely  small  and  frc(|uent  |)ulse.  In  such 
patients  retarded  and  irrci^itlar  pulse  is  never  present,  as  well  as 
the  irregular  respiration  with  deep  sighings ;  on  the  contrary  the 
]:)reathing  is  ahd'ays  slialloic  and  much  acclerated  (alx)ut  80  to 
100  per  minute). 

The  same  clinical  picture  may  be  obtained  even  without 
whooping-cough,  provided  there  exist  some  other  causes  for  the 
venous  stasis  in  the  brain,  for  instance,  in  the  case  of  thrombosis 
of  the  vessels,  so  that  one  must  be  very  careful  with  the  diagnosis 
of  tubercular  meningitis  in  those  cases  where  we  have  to  do  with 
a  cyanotic  patient  or  when  the  patient  shows  other  signs  of 
heart-failure,  as  well  as  in  cases  where  there  is  some  reason 
to  suppose  the  possibility  of  development  of  thrombosis  of  the 

SINUSES. 

The  latter  process  most  often  complicates  otites  associated 
with  carious  destruction  of  the  temporal  bone;  in  other  cases 
the  cause  of  thrombosis  is  blood-stagnation  in  the  veins  of  the 
head,  for  instance,  compression  of  the  upper  vena  cava  by  en- 
larged glands,  or  weakened  heart-activity  under  the  influence  of 
(liarrhcea  and  other  exhausting  diseases,  among  these  also  acute 
febrile  processes. 

In  some  cases  the  thrombosis  of  the  sinuses  may  be  recog- 
nized during  life-time,  namely,  if  associated  with  different  cere- 
bral symptoms  of  diffuse  affection  of  the  brain  (vomiting,  head- 
ache, somnolence,  strabismus,  contracture  of  the  neck)  there  also 
appear  some  symptoms  which  especially  point  toward  thrombosis 
of  this  or  that  sinus;  as  in  case  of  impermeability  of  the  trans- 
verse sinus  a  solid,  oedematous  swelling  behind  the  ear  (for  the 
development  of  this  symptom  the  thrombosis  must  spread  to  the 
post  auricular  veins)  and  the  ischccmia  of  the  external' jugular 
vein  on  the  diseased  side.  (These  veins  are  in  children  not  gen- 
erally accessible  to  palpation,  therefore,  this  sign  hardly  ever  oc- 
curs in  pediatric  practice).     In  the  thrombosis  of  the  cavernous 


DISEASES    OF    THE    NERVOUS    SYSTEM  457 

rsinus  there  may  be  a  slis^ht  protrusion  of  the  eye-ball  (due  to 
stasis  in  the  ()i)hthalmic  vein),  (edema  of  the  e\e-lids  and  some- 
times of  the  entire  half  of  the  faee.  In  case  the  superior  longi- 
tudinal sinus  is  closed  then  we  have  cyanosis  of  the  face,  dilata- 
tion of  the  veins  extending-  from  the  parietal  to  the  temporal 
region  and  nose-bleed.  Unfortunately,  these  characteristic  symp- 
toms of  thrombosis  are  far  from  being  evident  in  all  cases,  there- 
fore the  diagnosis  often  remains  a  mere  supposition. 

Purulent  inflammaiion  of  the  pia  mater  of  the  brain 
.(mciii)ii::itis  simples  s.  piintlciitaj.  This  morbid  form  differs 
from  tuberctdar  meningitis  not  so  much  by  the  (juality  of  the 
;symptoms,  as  by  their  grouping  and  rapidity  of  course,  as  well  as 
by  the  aetiology,  which  has  been  already  spoken  of.  It  is  difficult 
to  point  out  some  symptoms  of  tubercular  n>eningitis  which  would 
not  be  met  with  also  in  meningitis  simplex.  In  distinction  from 
tubercular  meningitis  characterized  by  a  slow  course  and  gradual 
•develo])ment  of  symptoms  of  brain  pressure,  purulent  meningitis 
starts  at  once,  that  is,  without  any  premonition,  and  very  acutely, 
with  chills,  severe  headache,  vomiting  and  rapid  elevation  of 
temperature  up  to  40  degrees  C.  (104  degrees  F.).  In  tubercular 
meningitis  the  child  during  the  first  week  does  not  give  the  im- 
pression of  being  in  a  dangerous  condition ;  he  only  complains  of 
a  moderate  headache  and  dizziness  and,  being  in  the  state  of 
apathy,  but  in  complete  consciousness,  lies  in  bed  entirely  quiet : 
while  in  the  purulent  form  of  meningitis  even  at  the  end  of  the 
first  twenty-four  hours  or  during  the  second  d^y,  the  patient  is 
either  very  restless  (throwing  himself  about  in  the  bed),  or  is 
delirious  ( jum|)s  up  and  usually  manifests  symptoms  of  im- 
paired psychical  condition  and  blunted  consciousness).  He  pro- 
duces the  i)}ipressioii  of  serious  illness  from  the  -rery  first.  In 
about  three  or  four  days  the  consciousness  disappears  entirely. 
local  (in  the  face)  or  general  convulsions  and  somnolence  follow 
and  toward  the  end  of  the  week,  or  even  earlier,  death  results. 

It  is  the  rapidity  of  development  of  the  symptoms  and  the 
■quick  occurrence  of  the  fatal  termination  that  constitutes  the 
main  difference  between  purulent  meningitis  and  the  tubercular 
form. 

xA.s  to  separate  symptoms  these,  as  alread\  stated,  do  not  fur- 
nish any  positive  support  in  the  diagnosis. 


458  DISEASES    OF    THE    NERVOUS    SYSTEM 

Headache  in  the  purulent  form  is  from  the  very  first  of 
greater  severity  than  in  the  tubercular  inflammation  ;  z'oniiting 
and  constipation  are  in  both  cases  nearly  the  same,  but  the  re- 
tracted abdomen  is  more  pronounced  in  the  tubercular  form  (per- 
haps, because  the  latter  is  of  longer  duration,  as  during  the  first 
days  here  also  the  abdomen  is  not  much  retracted).  Symptoms 
of  brain  pressure  in  the  form  of  a  retarded  and  irregular  pulse 
and  wide,  non-reacting  pupils  may  be  completely  absent  in  simple 
meningitis  (during  the  first  days  the  pulse  is  always  accelerated 
proportionally  to  the  temperature,  and  full,  while  the  pupils  are 
narrowed)  namely,  in  those  cases  where  the  choroidal  plexuses 
are  not  involved  in  the  inflammation  and  thus  distension  of  the 
ventricles  is  absent.  ( )n  the  contrary,  there  is  also  noted,  in  simple 
meningitis,  a  retarded  and  irregular  jnilsc.  but  only  because  of 
fever  not  of  such  a  degree. 

The  involvement  of  the  facial  and  eye  nerves  arising  at  the 
base  of  the  brain,  is  more  pronounced  and  of  greater  constancy  in 
basilar  meningitis  than  during  inflammation  of  the  membranes  of 
the  convexity  of  the  brain. 

Fever  in  tubercular  meningitis  is  moderate  (about  38.5  de- 
grees C. — 101.3  degrees  F.),  and  may  be  entirely  absent  in  the 
period  of  highest  development  of  the  disease ;  while  in  purulent 
meningitis  fever  from  the  very  first  is  high  (about  40  degrees  C, 
— 104  degrees  F.),  remaining  near  this  point  until  the  very  end- 
In  general  one  can  say  that  in  their  typical  manifestations 
both  these  fomis  dififer  very  distinctly  from  each  other,  but  both 
are  sometimes  irregular,  and  then  the  differential  diagnosis  may 
be  surrounded  with  great  difficulties,  especially  if  the  history  is 
deficient  and  aetiological  elements  absent.  For  instance,  tuber- 
cular meningitis  assumes  a  very  rapid  course,  ending  with  death 
in  a  few  days,  if  it  develops  in  a  child  during  the  last  stage  of 
consumption  (Barthez  and  Rilliet)  or  if  the  eruption  of  tubercles 
be  accompanied  by  purulent  inflammation  not  only  of  the  base  of 
the  brain,  but  also  of  the  convexity  of  the  hemispheres.  Then 
the  correct  estimation  of  the  symptoms  may  be  effected  only  in. 
connection  with  the  history  and  the  known  causative  conditions. 
On  the  other  hand  a  simple  purulent  meningitis  sometimes 
develops  quite  slowly,  and  spreading  to  the  base  of  the  brain  (and 


DISEASES    OF    THE    NERVOUS    SYSTEM  459 

sometimes  even  to  the  ventricles)  gives  the  SNinptonis  ut  acute 
hydrocephalus.  Such  a  course  is  frequently  observed  in  connec- 
tion with  chronic  otitis  with  caries  of  the  bone  or  even  without  the 
destruction  of  the  latter.  In  such  cases  meningitis  may  be  pre- 
ceded by  more  or  less  grave  cerebral  symptoms  which  depend 
upon  disorders  of  circulation  within  the  cranium  as  a  result  of 
thrombosis  of  the  sinuses,  or  inflammation  of  the  dura  mater  or, 
finally,  upon  abscess  formation  in  the  brain.  In  these  conditions 
the  cerebral  disease  may  become  protracted  for  a  few  weeks,  re- 
maining nevertheless  without  an  exact  diagnosis.  The  aetiology 
here  decides  but  little,  because  we  have  to  deal  with  exhausted 
and  scrofulous  children,  so  that  it  is  impossible  to  determine 
whether  they  were  taken  with  meningitis  under  the  influence  of 
a  tuberculous  taint,  or  from  some  local  disorder  on  the  part  of 
the  ear. 

Diseases  with  which  acute  purulent  meningitis  may  be  con- 
founded are  very  numerous  and  hence  diagnostic  errors  occur 
often.  As  has  probably  happened  with  many  other  physicians.  I 
have  often  made  mistakes  by  suspecting  meningitis  where  it  was 
absent.  The  reasons  leading  to  a  wrong  diagnosis  may  be  present 
in  the  course  of  all  acute  febrile  diseases  starting  with  severe 
fever,  vomiting  and  general  convulsions,  especially  those  diseases 
in  which  the  convulsions  are  repeated,  and  are  accompanied  by 
half-consciousness,  delirium,  or  sopor,  this  being  mosth'  char- 
acteristic of  grave  scarlet  fever,  small-pox  and  inflammation  of  the 
lung  apices. 

Touching  the  diagnosis  of  such  cases  I  have  spoken  in  the 
articles  on  eclampsia  and  pneumonia.  Here  I  will  but  add  the 
following : — All  these  three  infectious  diseases  become  likened  to 
meningitis  only  in  the  severest  instances,  in  which  there  is  a 
very  high  initial  temperature,  rather  little  peculiar  of  meningitis, 
so  that  if  on  the  first  or  the  second  day  of  the  disease  one  finds 
a  rectal  temperature  higher  than  40.5  degrees  C.  ( 104.9  degrees 
F.),  then  this  fact  is  strongly  against  meningitis. 

Of  the  above-mentioned  diseases  confounding  a  diagnosis 
scarlet  fever  first  of  all  becomes  defined.  The  early  appearance  of 
the  rash  causes  the  possible  doubt  of  the  physician  to  last  not 
longer  than  twenty-four  hours.  In  small-pox  the  rash  does  not 
appear  until  the  third  day,  and  if  there  are  no  data  in  the  history 


460  DISEASES    OF    THE    NERVOUS    SYSTEM 

concerning-  the  possibility  of  having-  contracted  sniall-pox,  and  if 
there  is  no  prodromal  petechial  rash,  then  the  diagnosis  may  be 
under  doubt  for  three  days.  Signs  of  vaccination  almost  certainly 
exclude  the  severe  form.  Pneumonia  of  the  summits  of  the  lungs 
may  not  become  clear  until  still  later,  for  instance  in  from  seven 
to  nine  days.  Against  meningitis  and  for  pneumonia  are  the 
following  data: — The  absence  of  the  cause  of  meningitis  of  the 
convexity  of  the  hemispheres  ;  the  onset  of  the  disease  with  snuffles 
(in  pneumonia  developing  from  la  grippe)  ;  very  high  tempera- 
tures (in  jineumonia  not  infrequently  41  to  41.5  degrees  or  even 
42  degrees  C. — 105.8  to  106.7  degrees  F.,  or  even  107.6  degrees 
F.)  ;  absence  of  jjaralyses  on  the  i^art  of  the  nerves  of  the  face 
and  the  eve,  as  well  as  of  contracture  of  the  neck  ( these  symptoms 
may  also  appear  during  pneumonia  occurring  with  repeated  con- 
vulsions, but  in  such  connection  they  are  very  uncommon,  while 
thev  are  fre(|uent  in  meningitis).  The  course  of  acute  purulent 
meningitis  is  marked  by  progressiveness,  and,  if  convulsions  have 
alreadv  set  in.  then  death  follows.  The  patient  is  worse  each 
day,  while  in  pneumonia  the  general  condition  for  several  days, 
despite  the  convulsions,  remains  in  statu  quo,  and  then,  accord- 
ing to  the  decline  of  the  inllammation,  the  cerebral  symptoms 
graduallv  or  rajjidly  disappear.  The  accelerated  breathing  is  of  no 
particular  diagnostic  value,  as  it  is  also  observed  during  acute 
meningitis  in  small  children.  Convulsive  forms  of  pneumonia 
occur  almost  exclusively  in  small  children  under  two  years  of 
age. 

In  other  febrile  diseases  beginning  w^ith  convulsions  dou!)t 
cannot  obtain  longer  than  one  day,  because  eclampsia  usually  is 
not  repeated,  the  consciousness  clears  very  soon  and  thus  there  is 
no  further  resemblance  to  meningitis. 

Regarding  headache  one  should  bear  in  mind  that  if  the  same 
depends  on  high  temperature  it  stops  with  the  appearance  of 
delirium  and  loss  of  consciousness,  while  in  acute  meningitis  the 
child  grasps  at  his  head  or  screams  even  in  the  period  of  uncon- 
sciousness. 

Afebrile  eclampsia,  even  if  repeated  and  therefore  accom- 
panied by  sopor  or  some  other  cerebral  symptoms,  cannot  be  con- 
fused with  acute  meningitis,  inasmuch  as  it  is  not  accompanied 
by  elevated  temperature. 


DISEASES    OF    THE    XER\'()US    SYSIEM  4^)  [ 

Of  cerebral  diseases  the  greatest  likeness  to  acute  purulent 
meningitis  may  be  represented  by  some  cases  of  epidemic  cereliro- 
spinal  meningitis  (about  which  see  below)  and  cases  of  Striim- 
pell's  acute  encephalitis,  which  has  been  spoken  of  in  the  section 
on  spastic  hemiplegia.  During  the  first  days  Striimpell's  encephali- 
tis can  hardly  be  recognized,  but  after  a  few  days,  when  all  cere- 
bral symptoms  disappear,  and  only  hemiplegia  remains,  then  the 
diagnosis  is  easily  distinguished. 

A  complete  similarity  to  meningitis  may  be  represented  by 
nrccnua,  that  is,  wherein  the  patient  had  nephritis  previous  to 
the  appearance  of  the  cerebral  symptoms  (headache,  vomiting, 
general  convulsions,  loss  of  consciousness  or  delirium)  ;  but  even 
if  the  history  be  unknown,  the  question  may  be  cleared  away  by 
the  examination  of  the  urine. 

Finally,  one  should  remember  iiitlaiiiiiiatioii  of  the  labyrinth 
which  is  also  accompanied  by  symptoms  of  meningitis.  This 
disease  begins,  while  the  patient  is  in  complete  health,  with  fever 
and  vomiting,  then  follow  other  cerebral  symptoms  in  the  form 
of  blunted  consciousness,  contracture  of  the  neck,  delirium  and 
somnolency.  After  a  few  days  the  patient  recovers,  but  remains 
deaf,  and  the  gait  is  unsteady  for  several  weeks. 

The  peculiarity  of  such  cases  consists  in  the  rapid  termina- 
tion in  convalescence  and  in  the  subsequent  deafness  of  both 
ears.  The  anatomical  basis  of  this  disease  is  not  yet  quite  definite ; 
some  authorities,  as,  for  instance,  Troltch*  hold  it  more  probable 
that  we  do  not  have  in  these  instances  labyrinthine  disease,  but 
a  circumscribed  inflammation  of  the  cerebral  membranes,  in  the 
area  of  the  exit  of  both  auditory  nerves,  that  is,  of  the  floor  of  the 
fourth  ventricle. 

It  is  very  difficult,  sometimes  impossible,  to  recognize  men- 
ingitis developing  during  some  acute  febrile  disease  which,  by 
itself,  because  of  the  severe  febrile  condition,  is  accompanied 
by  cerebral  symptoms.  The  perplexity  in  the  diagnosis  is  ex- 
plained by  the  fact  that,  as  Huguenin**  testifies,  "We  do  ncit 
know  of  such  a  symptom  which  is  constantly  present  in  all 
cases  and  which  does  not  occur  in  the  same  manner  without  men- 
ing-itis." 


*Gerhardt's  Haudbuch,  page   189. 

**Zii'insscii's  Haudbuch.  page  220  (Russian  edition 


462  DISEASES    OF    THE    NERVOUS    SYSTEM 

Of  comparatively  greater  significance  in  the  diagnosis  of 
meningitis  complicating  an  acute  disease  are :  the  quick  onset  of 
grave  delirium,  considerable  contracture  of  the  neck,  paralyses 
of  the  eye-muscles  and  venous  stasis  in  the  retina.  Perhaps  in 
such  cases  as  a  sure  criterion  there  will  be  Kernig's  sign,  con- 
sisting in  that  in  meningitis  the  change  of  the  recumbent  posture 
to  the  sitting  one  is  immediately  accompanied  by  contracture  of 
the  calf-muscles. 

[Kernig's  sign,  consisting  in  it  being  impossible  to 
obtain  complete  extension  of  the  legs  when  the  patient  is  in  a 
sitting  posture,  was  described  by  Kernig,  of  St.  Petersburg,  in 
the  year  1884.*  This  condition  was  noted  by  the  author  in  ojic 
case  of  purulent  meningitis,  complicated  by  nephritis,  in  six 
chronic  meningites,  in  one  case  of  tubercular  meningitis  and  in 
thirteen  cases  of  cerebro-spinal  meningitis.  Netter  had  23  cases 
of  meningitis ;  twelve  of  cerebro-spinal  meningitis,  eight  of  tuber- 
cular, three  of  a  mixed  form,  and  in  all  these  forms  he  observed 
the  presence  of  Kernig's  sign.**  This  sign  thus  seems  to  prove 
the  presence  of  meningitis  in  any  given  case  of  involvement  of 
the  spinal  membranes,  although  it  has  been  noted  in  other  morbid 
forms,  as  for  instance,  sciatica. 

Regarding  the  nature  of  this  sign,  some  authors,  as  Bull,**'' 
Cippolino,  Maragliano,****  explain  it  as  an  exaggeration  of  the 
normal  phenomenon,  while  Friis  views  it  as  an  irritation  of  the 
nerves  coming  from  cauda  equina  and  by  their  being  compressed 
by  the  exudate. — Earle.] 

Epidemic  cerebro-spinal  meningitis.  Meningitis  cerebro- 
spinalis  epidemica  more  resembles  in  its  symptoms  the  tubercular 
form  of  meningitis.  In  typical  cases  it  begins  at  once  without 
any  premonitory  signs,  with  considerable  fever,  vomiting  and 
severe  headache ;  soon  followed  by  blunted  consciousness,  de- 
lirium, restlessness,  then  convulsions,  sopor  and,  toward  the  end  of 
the  week,  death. 

The  clinical  determination  of  these  cases  from  meningitis 
purulenta   simplex   follows   from   the   anatomical   nature   of   the 

*Berl.  Klin.  Woch.,  29  December,  1884. 
**La  Semaine  Medicalc,  1898,  pp.  281-284. 
***Berl.  Klin.  Wochenschr.  Novemb.  28.  1885. 
****Quoted  from  Piery;  Lyon  Medicale,  April,  1903. 


DISEASES    OF    THE    NERVOUS    SYSTEM  463 

lesion.  This  difference  consists  in  that  the  symptoms  of  affec- 
tion of  the  cerebral  meninges  are  compHcated  by  those  on  the 
part  of  the  spinal  cord  in  the  form  of  early  occurring  contracture 
of  the  occipital  and  head  muscles  (usually  from  the  second  up 
to  the  fifth  day),  severe  painfulness  in  the  spine  upon  each  move- 
ment and  upon  pressure  over  the  spinous  processes,  especially 
in  the  lumbar  and  cervical  portions  of  the  vertebral  column,  de- 
cidedly developed  hyperaesthesia  of  the  skin  (especially  of  the 
legs)  and  pains  in  the  limbs  (involvement  of  the  posterior  roots 
in  the  inflammation).  It  is  true  that  contracture  of  the  neck  and 
hyperaesthesia  of  the  skin  are  frequently  met  with  also  during 
other  forms  of  meningitis  (purulent  and  tubercular),  but  then 
not  to  such  a  degree  and  without  the  painfulness  in  the  spine. 
As  a  characteristic  of  the  disease  in  question  may  be  noted  an 
eruption  of  herpes  zoster  and  attention  is  directed  to  the  articula- 
tions, owing  to  the  concurrence  of  acute  synovitis.  Although  both 
these  symptoms  are  unnecessary  to  the  confirmation  of  cerebro- 
spinal meningitis,  nevertheless  they  occur  very  often. 

Cerebro-spinal  meningitis  also  differs  from  a  common  one 
by  the  peculiarities  of  its  course.  Only  in  severe  cases  of  the 
latter  does  death  set  in  after  a  few  days  from  a  single  symptom- 
group  onset.  Usually  the  course  of  epidemic  meningitis  differs 
by  great  irregularity  on  the  part  of  the  fever,  as  well  as  on  that 
of  all  other  symptoms ;  the  disease  appears  to  be  liable  to  changes 
by  way  of  amelioration  and  then  new  aggravations  (wave-like 
course).  After  a  few  days  from  the  beginning  of  the  disease 
the  temperature  commences  to  fall  with  the  simultaneous  sub- 
sidence of  the  nervous  symptoms ;  then  after  a  few  days  more 
an  apparent  relapse  occurs,  and  thus  the  case  can  be  protracted 
for  a  few  weeks  and  even  months.  Recovery  finally  sometimes 
happens  but  it  is  rarely  complete  because  there  usually  remain 
some  paralytic  sequences  in  the  form,  for  instance,  of  deafness, 
blindness,  mental  derangement  and  paralyses  of  the  limbs.  In 
some  cases  the  wave-like  course  of  meningitis  assumes  a  purely 
intermittent  character  simulating  intermittens  quotidiana  (see 
malarial  fever)  ;  such  an  intermitting  course  may  be  observed 
from  the  very  first  day  of  the  disease.  I  had  the  opportunit\-  of 
watching  such  a  form  in  a  ten-year-old  child  who  became  ill 
with  vomiting  and  headache  while  in  seemingly  perfect  health  ; 


464  DISEASES    OF    THE    NERVOUS    SYSTEM 

after  a  few  hours  the  headache  ceased,  but  on  the  following  day  it 
reappeared,  commencing  at  four  o'clock  in  the  morning,  accom- 
panied by  violent  restlessness  and  blunted  consciousness.  Then 
from  five  o'clock  in  the  evening  to  midnight  all  symptoms  disap- 
peared. Then  a  new  restlessness  came  on  with  loss  of  conscious- 
ness and  at  three  o'clock  death  resulted. 

Like  all  other  epidemic  diseases  cerebro-spinal  meningitis- 
exhibits  great  variations  regarding  the  intensity  of  the  disease. 
There  exist  all  possible  transitory  forms  between  the  most  intense 
cases  starting  at  once  with  convulsions  and  sopor  and  terminating 
with  death  in  a  few  hours  (meningitis  sidcrans)  and  the  mildest,, 
so-called  atortive  cases,  which  are  characterized  by  headache, 
slight  febrile  condition  and  insignificant  contracture  of  the  neck. 
The  diagnosis  of  these  extreme  forms,  that  is,  the  severest  and 
the  mildest  cases,  is  possible  only  during  the  existence  of  an 
epidemic. 

I  will  mention  two  more  symptoms  which,  while  not  very 
necessary  or  indicative  of  meningitis,  may  yet  be  of  some  aid  when 
present. 

I  refer  to  ( i )  the  roseolae  which  usually  appear  upon  the 
trunk,  giving  rise  therefore  to  a  suspicion  of  typhoid,  especially 
if  the  spleen  be  simultaneously  enlarged;  and,  (2)  inflammation 
of  the  joints,  which  suggest  acute  rheumatism.  In  both  events 
the  diagnosis  of  meningitis  may  be  made  from  the  fact  of  the 
early  appearance  of  the  cerebral  symptoms  and  their  severe 
development.  I  point  out,  by  the  way,  that  in  one  of  my  cases  of 
cerebro-spinal  meningitis  in  a  one-year-old  child  serous  synovitis 
of  both  knee  joints,  with  contracture  of  the  legs,  appeared  from 
the  first  days  of  the  disease  (the  fourth  day)  and  lasted  during  the 
whole  course  of  meningitis  (many  weeks),  and  some  time  after 
recovery ;  the  contracture  of  the  legs  required  massage  during  a 
whole  month  after  that. 

That  cerebro-spinal  or  tubercular  meningitis  may  be  con- 
founded with  cervical  rheumatism  is  proven,  for  instance,  by  the- 
following  case  of  Cadet  de  Gassicourt* : — 

A  boy,  four  years  of  age,  whose  brother  died  from  tubercular 
meningitis,  took  suddenly  sick  with  repeated  vomiting  three  days 
previous  to  entrance  to  the  hospital;  soon  after  there  was  con- 

*Arch.  f.  Kindcrkr.    X  B.,  page  397. 


DISEASES    OF    THE    NERVOUS    SYSTEM  4t')5 

stipation,  severe  headache,  restlessness,  cry  from  pain.  The  ex- 
amination showed  dehrium,  apathy,  sucking  movements  and  j^rind- 
ing  of  the  teeth  ;  the  pulse,  one  hundred,  irregular ;  sighing  res])ira- 
tion  ;  the  temperature  39  degrees  C.  (102.2  degrees  F.).  Further, 
contracture  of  the  neck  and  hyperaesthesia  of  the  skin  of  the  face 
made  themselves  evident ;  the  pupils  were  dilated,  unequally ; 
the  abdomen  not  retracted.  The  diagnosis  was  meningitis  tuber- 
culosa (in  view  of  the  foudroyant  onset,  severe  delirium,  marked 
contracture  of  the  neck,  small  retarded  pulse  and  hypersesthesia). 
A  more  correct  diagnosis,  in  my  opinion,  would  have  been  cerebro- 
spinal meningitis.  In  the  following  two  days  there  was  increase 
of  the  contracture  of  the  neck ;  on  the  eighth  day  the  general 
condition  was  without  change,  but  Trousseau's  cerebral  spots 
appeared  ;  the  patient  emitted  loud  cries  when  he  was  seated  in  the 
bed,  his  head  remained  immovable ;  upon  examination  of  the  neck 
a  severe  painfulness  was  found  in  the  area  of  the  fourth  and  fifth 
vertebrae;  the  head  could  be  easily  turned,  but  bending  of  it  was 
impossible.  The  diagntisis  then  made  was  :  rheumatismus  cervi- 
calis.  The  further  course  in  Cadet's  opinion  confirmed  this  diag- 
nosis, because  toward  the  thirteenth  day  all  symptoms  disappear- 
ed, and  in  a  few  days  the  patient  was  discharged  from  the  hospital 
in  a  healthy  condition. 

[Besides  the  two  above-mentioned  valual)le  methods  of  the 
diagnosis  of  meningitis  there  have  lately  been  proposed  some 
other  procedures,  of  which  we  shall  name  only  that  of  Widal, 
Sicard  and  Ravault  ("c}to-diagnosis")  and  Uard's  methods 
("haemolysis").  The  principle  of  the  former  consists  in  the  fol- 
lowing :  The  normal  cerebro-spinal  fluid  does  not  contain  any 
cells,  or  if  so  a  very  small  number  (one  or  two  in  the  field  of 
the  microscope)  ;  however,  in  cases  of  meningitis  the  cerebro- 
spinal fluid  then  contains  an  increased  number  of  elements — 
lyin/^hocytcs.  The  investigators  mentioned  give  an  elaborate 
technique  of  examination  of  the  spinal  fluid  for  this  purpose*, 
but  here  we  quote  the  method  employed  by  Hastings  in  Dana's 
cases  ( New  York)  described  in  the  Medical  Record.  January  21,, 
1904,  p.  124:  "The  spinal  fluid  is  collected  directly  into 
sterilized    centrifuge    tubes    to    avoid    cell    contamination    and 


*See  Widal.  Sicard.  et  Ravault:  "A  propos  de  Cytodiagnostic,"  Rr:  uc 
Neurolgiquc.  No.  6.  1903. 


466  DISEASES    OF    THE    NERVOUS    SYSTEM 

<lisintegration  of  cellular  elements,  brought  alxsut  in  part 
at  least  by  bacterial  action  often  occurring-  in  imperfectly  cleansed 
tubes,  similar  to  the  disintegration  of  casts  by  bacteria  in  urine 
containing  various  forms  of  bacteria  from  outside  contamination. 
As  a  rule  the  fluid  is  examined  within  two  hours  after  tapping, 
although  in  sterile  tubes  the  cells  in  the  fluid  remain  intact  24 
to  48  hours,  with  no  variation  in  the  number  of  cells.  Six  c.  c.  of 
fluid  are  centrifugated  at  1,800  to  2,400  revolutions  a  minute  for 
fifteen  minutes,  revolutions  above  1,800  resulting  in  little  or  no 
variation  in  the  number  of  cellular  elements  in  a  capillary  drop 
after  fifteen  minutes'  centrifugation.  After  centrifugation  the 
tube  is  inverted,  the  fluid  thus  poured  off,  and  from  the  small 
amcnuit  of  remaining  fluid  a  drop  is  drawn  up  in  a  capillary 
pipette,  blown  out  on  a  slide,  covered  with  a  seven-eighth-inch 
coverslip  and  examined  with  a  Leitz  No.  iv.  ocular,  No.  7  ob- 
jective. 

For  sedimenting  and  centrifugaticMi  Napp's  (Munch.  Medic. 
IVochenschr.  T903  No.  38,  p.  1.639)  two-piece  centrifuge  tubes 
may  be  used,  but  with  no  advantage  over  the  use  of  a  capillary 
pipette. 

For  estimating  the  approximate  number  of  cells  in  the  drop 
spread  over  a  fixed  area  an  Ehrlich's  eye-piece  with  the  widest 
field  is  used,  the  total  number  of  cellular  elements,  excepting  red 
cells  and  polynuclear  cells  in  100  fields  is  recorded  and  the  average 
for  one  field  estimated.  Thtis  the  cells  are  counted  over  approxi- 
mately the  same  area  for  every  specimen  and  without  manijiula- 
tion  other  than  centrifugation.  The  variation  in  number  of  cells 
at  periphery  and  at  center  of  the  covered  drop  is  practically  nil. 
Estimating  the  relative  number  of  cells  in  fresh,  wet  specimens 
gives  results  slightly  below  those  obtained  by  counting  the  cells 
per  field  in  the  dried  and  stained  specimens. 

In  negative  (normal)  specimens  a  careful  searching  over 
3-6  slides  may  reveal  a  few  (under  10-12)  lymphoid  cells  and 
red  cells.  For  dififerential  counting  the  drop  of  centrifugated 
fluid  is  mixed  with  a  drop  of  Loftler's  methylene  blue,  and  if  the 
cells  are  sufficiently  numerous  100,  200,  or  more  cells  are  counted 
differentially,  being  classed  as  polynuclear,  small  mononuclear, 
and  large  mononuclear ;  rarely  typical  large  epithelioid  cells  are 
found  and  classed  as  such.     For  the  purpose  of  differentiating 


DISKASKS    OF    'II1I-:    N  I:K\()IS    SVSrKNF  407 

eosiiu>])hilic  and  oiIut  i^ranulations.  dryiiii;',  fixing,  and  stainin<(^ 
as  reconmK'ndcd  by  W'idal,  arc  necessary.  Specimens  drieil  in 
the  air  and  stained  with  Jenner's,  Leishnian's,  or  Wright's  stain 
g-ive  i^ood  results,  but  since  the  cytolof^ic  formuhe  are  based  u])on 
polynuclear.  mononuclear,  and  epithelioid  types  of  cells,  the  study 
of  such  preparations  is  of  little  value.  While  all  types  of  normal 
blood  cells,  excepting  the  mast  cell,  have  been  found  in  s])inal 
fluid,  the  value  of  the  differential  count  lies  in  the  detc-nuinalion 
of  the  relative  proportions  of  polynuclear  and  mononuclear  ele- 
ments— thedetenuination  of  a  polynucleosis  or  of  a  mononucleosis 
— and  a  division  of  the  mononuclear  forms  into  'small'  and  'large' 
is  unnecessary." 

The  second  method,  that  of  Bard  "hsemolytic  power  of  the 
cerebro-spinal  fluid."  is  based  on  the  power  of  the  cerebro-spinal 
fluid  under  some  conditions  (abnormal)  to  dissolve  red-blond 
corpuscles.  The  spinal  fluid  of  the  patient  is  diluted  with  distilled 
water  in  various  quantities  then  mixed  with  one  droj)  of  blood, 
shaken  and  centrifugated,  when  one  should  notice  if  the  superja- 
cent fluid  be  colored  or  colorless :  in  the  former  case  we  have 
haemolysis,  in  the  latter  not.  The  degree  of  the  hsemolytic  power 
is  judged  from  the  amount  of  water  added  to  the  cerebro-spinal 
fluid  to  dissolve  the  drop  of  blood — the  less  water  added  the  higher 
is  the  hemolytic  power  of  the  spinal  fluid.  This  power  is  increased 
in  cases  of  meningitis   (Bard)*. 

Of  other  new  methods  of  diagnosing  meningitis  and  deter- 
mining the  difl^erent  forms  thereof  we  refer  the  reader  to  special 
articles  or  to  the  general  review  of  this  subject  made  by  Tre- 
molieres  in  the  Gazette  des  Hopitanx,  November  7th  and  Xovem- 
ber  loth.   1903**. — Earlk.  J 

Fal.se  meningitis.  L  nder  the  name  of  false  meningitis 
there  are  described  in  literature  cases  in  which  cerebral  s\  niptoms 
simulating  meningitis  appear,  while  in  reality  there  is  no  men- 
ingitis. The  patient  either  soon  recovers,  or.  if  he  dies,  the 
necropsy  shows  the  cerebral  meninges  to  be  entirel\    normal. 

In  their  origin  and  causes  cases  of  false  meningitis  are  very 
diverse  and  may  be  classified  in  three  groups. 


*L.  Bard:  Des  variations  palholcigiqucs  du  pouvoir  Iieiimlytiqiu'  du 
liquide  cephalorachidien   (La  Scmaiiic  Med..  Jan.  14.  1903.  pj).  9-IJ). 

**Sce  an  extensive  abstract  of  this  review  in  The  Scottisli  Mcdiriil  and 
Surgical  Jounial.  Feljruary,  1904.  pp.  164-167;  also   167,   168. 


468  DISEASES    OF    THE    NERVOUS    SYSTEM 

In  the  first  we  include  cases  of  false  meningitis  arising  vmder 
the  influence  of  acute  infcctioits  diseases.  The  first  place  in  this 
group  belongs,  undoubtedly,  to  croupous  pneumonia  in  small 
children.  It  is  a  well-established  fact  that  pneumoniae  of  the  pul- 
monary summits  are  those  which  are  most  often  complicated  by 
cerebral  symptoms,  so  that  such  symptoms  are  even  described 
under  the  name  of  cerebral  pneumoniae.  They  occur  with  vomit- 
ing, high  temperature  and  repeated  convulsions  very  like  acute 
purulent  meningitis,  but  usually  terminating  with  rapid  recov- 
ery. 

In  the  second  place,  among  the  acute  febrile  diseases,  existing 
sometimes  under  the  mask  of  meningitis,  I  put  la  grippe.  Many 
opportunities  have  come  to  me  of  seeing  cases  of  influenza  which 
began  with  vomiting  and  headache,  and  which  after  that  con- 
tinued with  moderate  fever,  a])athy  and  constipation,  in  a  word, 
simulating  tubercular  meningitis. 

In  other  instances  influenza  resembles  acute  meningitis.  The 
illness  begins  either  immediately  with  the  attack  of  general  con- 
vulsions, or  with  violent  fever,  headache  and  vomiting,  followed 
by  apathv,  blunted  consciousness,  contracture  of  the  neck,  even 
strabismus,  unecjual  pupils,  grinding  of  the  teeth,  general  h3'per- 
sesthesia,  retardation  of  the  pulse,  uneven  breathing ;  in  a  word, 
as  a  complete  ])icture  of  an  undoubted  meningitis.  But  after 
a  few  days  all  symptoms  disappear,  and  the  patient  rapidly  re- 
covers. The  diagnosis  of  these  cases,  before  the  period  of  im- 
provement, is  hardly  possible,  even  where  the  cerebral  symptoms 
appear  during  a  positive  influenza,  because  it  is  beyond  doubt  that 
the  latter  may  be  complicated  by  a  real  meningitis  of  purulent  or 
serous  character. 

To  the  second  group  we  refer  cases  of  false  meningitis  due 
to  some  poisoning.  Poisoning  in  childhood  usually  occurs  acci- 
dentally, from  immoderate  doses  of  some  drugs,  as,  for  instance, 
opium  and  other  narcotics,  or  remedies  producing  convulsions  to 
which,  among  others,  santonin,  for  instance,  belongs.  It  is  of 
practical  interest  that,  among  drugs  which  may  give  rise  to  the 
evidences  of  false  meningitis,  wine  also  be  included.  Only  re- 
cently I  observed  the  following  very  interesting  case : — I  had 
under  care  a  thirteen-month-old  child  that  became  sick  in  April 
vvith  fever  and  weakness.     He  was  cured  by  wine,   (port-wine) 


DISEASES    OF    THE    NERVOUS    SYSTEM  46*) 

which  was  ^iven  every  two  hours,  a  tcaspoonful  at  a  time.  Soon 
afterwards  ihc  jiatient  vomited  two  or  ihrrc  times,  lie  became 
lan.5>-uid  and  somnolent,  so  that  the  dose  of  wine  was  increased, 
and,  with  the  onset  of  somnolency,  I  was  called.  The  beginning 
of  the  disease  with  vomiting,  followed  by  somnolency  while  the 
fever  was  moderate,  without  cough  or  any  other  local  symptoms, 
all  strongly  pointed  toward  acute  hydrocephalus.  But  the  indica- 
tions, nevertheless,  were  not  entirely  complete;  there  were  absent 
■contracture  of  the  neck,  retarded  pulse,  deep  sighing.  T  onlv 
told  the  mother  that  the  child  had  some  cerebral  symptoms,  but 
as  to  the  further  course  I  could  not  say.  The  treatment  consisted 
in  suspending  the  wine  and  administering  valerian  dro])s.  The 
result  was  brilliant.  Even  upon  the  following  day  the  child  was 
-clamorous  and  restless,  and  after  one  or  two  days  more  entirely 
well. 

The  diagnosis  of  such  cases  is  not  difificult  if  there  be  a  minute 
•history  ;  but  much  more  perplexity  may  arise  in  some  forms  of  auto- 
intoxication  of  the  organism,  the  most  important  form  of  which 
is  unemia.  This  disease,  in  its  convulsive  stage,  may  completely 
simulate  acute  meningitis.  Here  the  physician  will  not  forget  to 
-examine  the  urine. 

To  the  third  group  belong  cases  of  false  meningitis  as  a 
manifestation  of  some  neurosis.  No  doubt  some  of  these  cases 
nia}"  be  ascribed  to  reflex  influences,  others  are  purely  hysteri- 
cal. 

To  reflex  false  meningitis  belong  cases  of  intestinal  origin,  of 
which  we  spoke  in  the  section  on  tubercular  meningitis.  It  is 
still  a  question  whether  these  cases  are  of  reflex  origin ;  it  may  be 
more  reasonable  to  suppose  auto-intoxication  of  the  organism  be- 
cause of  absorption  of  noxious  products  from  the  towels. 

As  a  typical  example  of  hysterical  false  meningitis  the  fol- 
lowing case  is  mentioned  : — 

A  girl,  scrofulous  in  childhood,  lost  an  older  sister  from 
meningitis.  Having  entered  school  she  became  languid  and 
melancholy  and  two  days  later  had  a  headache  of  two  days"  dura- 
tion, becoming  confined  to  the  bed.  She  could  hardly  sit  up  in 
bed  and  could  not  stand  up  at  all  because  of  dizziness.  She  was 
persistently  constipated,  and  the  pulse  was  retarded  and  not  en- 
tirelv  regular.     The  diagnosis  of  tubercular  meningitis  intruded 


470  DISEASES    OF    THE    NERVOUS    SYSTEM 

itself,  so  to  say,  as  in  favor  thereof  we  had  the  history  (death 
of  the  sister  from  meningitis,  scrofulosis  in  childhood),  the  exist- 
ence of  a  period  of  precursors  and  the  initial  vomiting,  and  finally 
the  presence  of  such  characteristic  meningeal  symptoms  as  head- 
ache, dizziness,  weakness,  apathy,  retarded  pulse  and  constipation. 
However,  upon  demonstrating  this  case  to  the  students  during  a 
lecture,  I  could  not  be  satisfied  with  the  diagnosis  of  tubercular 
meningitis,  because  this  was  contradicted  by  the  somewhat  ex- 
tended and  tense  abdomen,  as  well  as  by  the  duration  of  the  disease 
(since  the  time  of  vomiting  there  had  already  elapsed  nineteen 
days),  and  neither  contracture  of  the  neck,  nor  somnolency,  nor 
paralyses  on  the  part  of  the  eyes  or  in  the  distribution  of  other 
nerves  passing  over  the  base  of  the  brain  were  present. 

It  was  also  impossible  to  think  of  a  reflex  (or  toxsemic) 
pseudo-meningitis  due  to  constijiation,  Ijecause,  despite  the  laxa- 
tive which  had  been  administered  at  the  very  beginning  of  the 
disease  and  the  strict  diet,  the  condition  became  much  protracted. 

At  the  end  of  the  lecture,  and  in  the  presence  of  the  patient, 
I  said  that  one  should  not  become  altogether  discouraged  in  such 
instances,  it  being  nu>st  j^robable  that  in  a  week  the  patient  would 
be  able  to  walk. 

The  treatment  was  directed  towards  the  relief  of  the  con- 
stipation, consisting  of  daily  injections  and  a  glass  of  Carlsbad 
water  divided  into  three  doses.  The  result  of  the  treatment 
seemed  to  have  confirmed  the  intestinal  origin  of  the  disease^ 
because  one  day  later  the  patient  began  to  stand  up,  and  on  the 
following  day  to  walk.  I  think,  however,  that  the  relation  here 
was,  as  is  generally  found  in  cases  of  so-called  reflex  paralyses,, 
not  so  simple.  If,  for  instance,  the  paralysis  of  the  legs  disap- 
pears after  the  operation  of  phimosis  or  expulsion  of  worms,  then 
it  is  believed  that  the  phimosis,  or  the  worms,  caused  the  paraly- 
sis ;  but  there  is  another  explanation.  The  intestinal  worms  and 
phimosis  occur  quite  often,  while  paralyses,  in  connection  with 
these  diseases,  are  very  rare ;  it  follows,  therefore,  that  besides 
these  causes  a  soil  is  needed  also,  that  is,  a  j^articular  condition 
of  the  nervous  system,  the  essence  of  which  is  unknown.  We 
compare  such  a  nervous  condition  with  that  which  we  see  in 
hysteria  and  learn  that,  perhaps  not  so  much  the  intestinal  worms 
or  the  phimosis,  are  the  real  causes  of  the  paralyses,  as  hysteria,. 


DISEASES    OF    THE    NERVOUS    SYSTEM  47 1 

and,  since  hxslirical  children  easily  yield  to  suggestion,  it  is 
obvious  then  that  expulsion  of  the  worms  or  a  phimosis  operati<.>n, 
act  not  alone,  that  is,  not  by  the  way  of  removing  the  cause,  but 
through  the  intluence  of  suggestion  and  auto-suggestion.  As 
to  our  case,  I  l>elieve  that  we  had  the  so-called  pseudo-meningitis 
hysterica,  which  had  developed  under  the  iuHuence  of  some  acci- 
dental stomach  trouble  and  that  the  recovery  took  place,  not  be- 
cause of  the  Carlsbad,  but  through  the  aid  of  suggestion. 

The  girl  was  taken  before  the  clinic,  which  was  altogether  a 
strange  experience  for  her,  and  was  the  subject  of  a  lecture,  dur- 
ing which  she  heard  that  she  would  be  given  some  water,  and 
daily  enemata,  and  that  she  would  be  able  to  walk  in  a  few  days. 
As  hysterical  children  easily  yield  to  suggestion,  so  this  patient 
responded  to  the  circumstances,  arose  upon  her  feet  and  started  to 
walk. 

The  absence  of  the  hysterical  stigmata,  as  anaesthesia  or 
hyperassthesia,  of  course,  cannot  exclude  hysteria,  because  these 
stigmata  are  not  constant ;  the  heredity  of  the  patient  because  of 
lack  of  family  history  was  not  definite,  but  that  the  patient  was 
"nervous,"  could  be  seen  from  the  fact  that  her  disposition  be- 
came changed  from  the  moment  of  her  entrance  into  the  school. 
Besides  this  the  aunt,  who  came  to  take  the  patient  from  the  hos- 
pital, told  us  that  on  the  day  previous  to  the  vomiting  something 
Strange  happened  to  the  girl — she  was  very  excited  and  even 
suddenly  began  to  sing  in  the  school-room  during  the  lesson.  Such 
an  eccentricity  scarcely  indicates  a  normal  condition  of  the  nervous 
system. 

In  a  word,  my  opinion  as  to  this  case  is  the  following: — 
This  was  a  case  of  hysterical  astasia-abasia  which,  because 
of  occasional  vomiting  and  some  quite  common  symptoms  of 
hysteria,  as  constipation,  retarded  pulse  and  headache,  appeared 
as  tubercular  meningitis,  that  is,  the  condition  described  under  the 
name  of  pseudo-meningitis  hysterica. 

A  still  more  striking  case  was  described  by  ( ^llivier"^'.  A 
six-year-old  girl,  having  a  tuberculous  father  and  being  of  a  very 
weak  constitution,  suffered  for  eight  days  with  constant  head- 
ache. consti])ation  and  somnolency.  ( )ne  day  she  was  found  by 
Ollivier  in  the  ])osture  of  "k'  chien  a  fusil"  :  he  noted  iihotoplK)l)ia, 


"Rcz'iic  )iu-iis.  ih's  maladies  dc  I'mf.  1891.  pag^o  573. 


472  DISl'lASl'lS    01--    Tllli    NERVOUS    SYSTEM 

cutaneous  hypersesthesia,  grinding  of  the  teeth,  retracted  abdomen,, 
retarded  and  irregular  pulse,  dilated  pupils,  nystagmus ;  later  on- 
there  appeared  the  hydrocephalic  cry,  convulsive  movements  in 
the  limbs,  delirium  and  finally  somnolency.     Some  days  after  that 
gradual  improvement  appeared,  and  after  six  weeks  the  girl  went 
away  to  the  country.    Ollivier  looked  upon  this  case  as  an  example^ 
of  recovery  from  tubercular  meningitis ;  but  when  later  on  the- 
picture  of  hysteria  developed  in  the  girl,  (causeless  laughing  or 
crying,  night  terror,  intercostal  neuralgic  pains,  pain  in  the  spine), 
then  he  changed  his  opinion  and  described  this  case  under  the- 
name  of  hysterical  pseudo-  (false)  meningitis. 

These  cases  of  hysteria  differ  from  an  actual  meningitis  by 
the  absence  of  fever,  changes  of  the  fundus  of  the  eye  (cfidema 
papillae,  neuritis  optica),  paralyses  of  the  facial  nerve  and  the 
eye  nerves,  unequal  pupils,  strabismus  and  of  any  local  symptoms 
in  general. 

I  Peters  refers  to  17  cases  of  pseudo-meningitis  in  children 
from  the  ninth  month  to  the  thirteenth  year.  Eleven  of  these 
occurred  hefore  the  fifth  year ;  seven  occurred  with  typhoid ;  three 
with  influenza ;  one  with  croupous  pneumonia;  two  with  gastro- 
intestinal disorder;  two  with  mixed  infections  of  intluenza  and 
streptococcus.  In  15  there  was  complete  recovery;  one  case  be- 
came an  idiot  and  one  died. 

The  author  considers  the  differential  diagnosis  between 
pseudo-meningitis  and  genuine  meningitis,  and  believes  the  fol- 
lowing points  important : 

( 1 )  If  convulsions  occur  in  pseudo-meningitis  they  are 
tetanoid  or  tonic  in  character ;  are  restricted  to  certain  groups  of 
muscles,  and  are  not  followed  by  prolonged  unconsciousness. 

(2)  With  the  beginning  of  pseudo-meningitis,  a  reduction- 
of  temperature  occurs. 

(3)  In  the  further  course,  bulbar  symptoms,  as  irregular  pulse 
and  respiration,  are  absent. 

(4)  The  amount  of  cerebro-spinal  fluid  is  not  increased. 
(.0  Delirium  is  frequently  observed.    In  four  cases  the  author 

observed    an    acute    psychosis    following    the   pseudo-meningitis. 
Urcemiawa.s  absolutely  excluded  in  the  seventeen  cases.* — Earle.] 

*Russ.  Arch  f.  Pathol.,  etc.    Bd.  XIII.,  No.  3  (Quoted  from  The  Prac— 
tical  Medicine  Series  of  Year  Books,  June,  1903,  ed.  by  Abt,  p.  174). 


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